Quality Improvement Plan Guidance Document

January, 2011

Ontario.ca/ExcellentCare

Table of Contents
Acknowledgements................................................................................................................. 3 A. Purpose................................................................................................................................ 4 Purpose of this Guidance Document...................................................................................... 4 Purpose of the Excellent Care for All Acts Quality Improvement Plan...................................... 4

B. Background. ........................................................................................................................ 5 Definition of Quality................................................................................................................. 5 Process Guidance.................................................................................................................. 5 Roles & Responsibilities for the Quality Improvement Plan...................................................... 6 Development and Submission Process:. ................................................................................. 8 Reporting to the OHQC:......................................................................................................... 9 Public Posting:....................................................................................................................... 9

C. Content Guidance............................................................................................................... 9  Part A: Overview of Our Hospitals Quality Improvement Plan. ................................................. 9  Part B: Quality Improvement Plan Our Improvement Targets and Initiatives................................................................................. 9 1. Columns...................................................................................................................... 9 2. Rows. ........................................................................................................................ 11

 Part C: The Link to Performance-based Compensation of Our Executives............................ 12 Part D: Accountability Sign-off.............................................................................................. 13

Appendix A: Quality Improvement 101................................................................................. 14 Appendix B: Indicator definitions and technical information. ........................................... 17 Appendix C: Examples of other indicators to include in the QIP. ..................................... 20 Appendix D: Guidance on designing Overview of Our Hospitals Quality Improvement Plan (Part A)...................................................................................... 23 Appendix E: Guidance on performance based compensation.......................................... 25 Appendix F: Example of completed row in QIP................................................................... 30

Acknowledgements
This guide, and all of the support elements associated with the Quality Improvement Plan, have been developed in collaboration with hospitals, LHINs, the Ontario Health Quality Council, the Ontario Hospital Association, and the Ministry of Health and Long-Term Care. The Quality Improvement Plan Task Group would like to recognize the guidance and contribution of the ECFAA Implementation Working Group, as well as all of the hospitals involved in the field testing process. Quality Improvement Plan Task Group: Kelly Gillis, South West Local Health Integration Network Sudha Kutty, Ontario Hospital Association Nizar Ladak, Ontario Health Quality Council Cyrelle Muskat, Ontario Hospital Association Margo Orchard, Ministry of Health and Long-Term Care Jillian Paul, Ministry of Health and Long-Term Care ECFAA Implementation Working Group: Tai Huynh, Director, Excellent Care for All Strategy, MOHLTC (Chair) Anthony Dale, Vice President, Policy and Public Affairs, OHA Elizabeth Carlton, Director, Policy & Legislative/Legal Affairs, OHA Laura Kokocinski, CEO, North West Local Health Integration Network Kim Baker, CEO, Central Local Health Integration Network Ben Chan, CEO, Ontario Health Quality Council Nizar Ladak, Chief Operating Officer, Ontario Health Quality Council Ray Hunt, Chief Executive Officer, Espanola Regional Hospital and Health Centre Sharon Pierson, Director, Quality, Patient Safety and Clinical Resource Management, Hamilton Health Sciences Carolyn Baker, President and CEO, St. Josephs Health Centre Jillian Paul, Project Lead, Excellent Care for All Strategy, MOHLTC Margo Orchard, Senior Consultant, Excellent Care for All Strategy, MOHLTC Maria van Dyk, Team Lead, Planning and Negotiations, LHIN Liaison Branch, MOHLTC Shannon Magennis, Senior Communications Advisor, MOHLTC For more information, please contact ecfaa@ontario.ca

This document is intended to provide public hospitals with guidance as to how they can satisfy the requirements related to quality improvement plans in the Excellent Care for All Act, 2010 (ECFAA). While much effort and care has gone into preparing this document, this document should not be relied on as legal advice and hospitals should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement plans. Furthermore, hospitals are free to design their own public quality improvement plans using alternative formats and contents, provided that they comply with the relevant requirements in ECFAA, and provided that they submit a version of their quality improvement plan to the OHQC in the format described herein.

A. Purpose
Purpose of this Guidance Document
The purpose of this guidance document is to offer assistance to health care organizations in their efforts to complete a Quality Improvement Plan (QIP) along with the QIP short form for submission to the Ontario Health Quality Council (OHQC).

Purpose of the Excellent Care for All Acts Quality Improvement Plan
The Excellent Care for All Act (ECFAA), which received royal assent in June 2010, is a landmark piece of legislation for Ontario. It fosters a culture of continuous quality improvement where the needs of patients come first. The introduction and implementation of this legislation is a clear indication to the people of Ontario that their health care providers and their government: Are committed to creating a positive patient experience and delivering high quality health care;  Are responsive and accountable to the public;  Believe that quality should be the goal of everyone involved in delivering health care in Ontario;  Understand that all health care organizations should hold their executive teams accountable for  its achievement; and Recognize the value of transparency. 
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The legislation requires that every health care organization (currently defined as a hospital within the meaning of the Public Hospitals Act): Establish a quality committee to report on quality-related issues;  Develop an annual quality improvement plan and make it available to the public;  Link executive compensation to the achievement of targets set out in the quality improvement plan;  Conduct patient / care provider satisfaction surveys;  Conduct staff surveys;  Develop a patient declaration of values following public consultation, if such a document is not currently  in place; and Establish a patient relations process to address and improve the patient experience. 
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According to the legislation, the annual QIP must be informed by the following: The results of the patient and employee surveys;  Data relating to the patient relations process;  In the case of a public hospital, its aggregated critical incident data as compiled based on disclosures  of critical incidents pursuant to regulations made under the Public Hospitals Act (PHA) and information concerning indicators of the quality of health care provided by the hospital disclosed pursuant to regulations made under the PHA.
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The annual QIP must contain at a minimum: Annual performance improvement targets and the justification for those targets;  Information concerning the manner in and extent to which, executive compensation is linked to the  achievement of those targets
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The QIP provides the means for hospitals to communicate to their public, patients, and staff that they are committed to accountability and transparency, and focused on creating a positive patient experience and delivering high quality health care. By holding their executive teams accountable for achieving targets in the plan, hospitals can use the QIP to help support the development of a high performing system. It goes without saying that a QIP should be an integrated part of a hospitals overall planning process. A high performing hospital organization combines and integrates a strategic plan, operational planning, its Hospital Annual

Planning Submission (HAPS), and Hospital Service Accountability Agreement (H-SAA). The integration of these documents helps ensure financial responsibility, accountability to patients, and high quality care. The QIP Short Form has been established to assist hospitals in meeting their legislative requirements and to providing the OHQC with quality improvement data and information in a format that permits province-wide comparison and reporting on a minimum set of quality indicators. This QIP short form is not intended to replace any existing quality improvement plans or strategies already in place in Ontario hospitals.

B. Background
The QIP Short Form has been established to assist hospitals in meeting their legislative requirements and to providing the OHQC with quality improvement data and information in a format that permits province-wide comparison and reporting on a minimum set of quality indicators. This QIP short form is not intended to replace any existing quality improvement plans or strategies already in place in Ontario hospitals.

Definition of Quality
The preamble to the ECFAA defines a high quality health care system in this way: accessible, appropriate, effective, efficient, equitable, integrated, patient centred, population health focused, and safe. The Ministry of Health and Long-Term Care, through the Excellent Care for All Strategy are committed to leveraging all nine of these attributes to advance quality initiatives across the province. In the fall 2010, a working group was formed to provide advice to the Ontario Ministry of Health and Long-Term Care around the design of QIPs. The consensus was that while all nine attributes are valuable, the QIP should specifically focus on four of them for streamlined provincial and public reporting: 1. Safe 2. Effective 3. Accessible 4. Patient Centred

Process Guidance
The QIP Short Form has been developed as a sample template Quality Improvement Plan to assist organizations with their quality improvement efforts while meeting the legislative requirements under the ECFAA. The QIP Short Form is a word document with an accompanying excel document that should be completed to show improvement targets and initiatives. Hospitals need to complete the following sections with any relevant information from their Quality Improvement Plans and submit to the OHQC (by emailing QIP@ohqc.ca) to ensure compliance with the section 8(5) of ECFAA1: 1. Overview of Our Hospitals Quality Improvement Plan (Part A)

This section is a brief description of an organizations QIP. It is divided into four areas:   Overview: A general statement that describes the organizations plan for the coming year.  Focus: A description of the objectives, measures and initiatives that have been identified to improve quality of services and care in the hospital, along with what resources are being used to implement improvement.  Alignment: An explanation of how this document links to the other planning documents developed by the organization.  Challenges, risks and mitigation strategies: A description of what unique circumstances might make it difficult to implement improvement.
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2. Our Improvement Targets and Initiatives (Part B)

 he Improvement Targets and Initiatives Spreadsheet is an excel file that should be completed to show the T improvement targets and initiatives that are part of the QIP. This section of the QIP has been designed to align with the Model for Improvement,2 with three essential  questions driving the improvement process: What are we trying to accomplish? AIM  How do we know that a change is an improvement? - MEASURE  What changes can we make that will result in the improvements we seek? CHANGE The excel file also contains a supporting read-me sheet that has been developed to provide more detailed  information to help organizations complete the section.
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3. The Link to Performance-based Compensation of Our Executives (Part C)

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 s required by the Legislation, organizations need to provide information concerning the manner in and A extent to which executive compensation is linked to the achievement of performance improvement targets. This section gives an overview of how this can be done.

4. Accountability Sign-off (Part D)

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This section ensures that all legislative requirements have been considered in the development of the QIP. 

Roles & Responsibilities for the Quality Improvement Plan

Ontario Health Quality Council: In an era of transparency and accountability, members of the public are increasingly well-informed and interested in the status of their health system. The OHQC was established to report to the public on the quality of health care in the province and support its improvement. With the passing of the ECFAA, the OHQC remains committed to monitoring and reporting to the people of Ontario. Starting in 2010, every hospital is required, under the Act, to provide a copy of its annual QIP to the OHQC in a format established by the Council that permits province-wide comparison of, and reporting on, a minimum set of quality indicators. Ministry of Health and Long-Term Care Improving the quality and value of the health care received by Ontarians is one of the Ministry of Health and Long-Term Cares priorities and a main goal of this legislation. The ECFAA supports this priority by strengthening the health care sectors organizational focus and accountability to deliver high quality patient care. The Ministry of Health and Long-Term Care established an implementation working group to assist Ontario organizations in their efforts to comply with the ECFAA. The ECFAA Implementation Working Group (ECFAA IWG) supports, guides, facilitates and coordinates implementation of the ECFAA and its regulations, as well as related quality initiatives, as detailed in its terms of reference. The working group consists of representatives from the Ministry of Health and Long-Term Care, the OHQC, OHA, LHINs, and hospitals across Ontario, and has led the process of developing the QIP template. Local Health Integration Networks: Health care organizations may be asked to provide their LHINs with a draft of their annual QIP for review before it is made available to the public. The LHIN may share feedback on the QIP with OHQC and the health care organization, particularly as it pertains to consistency with local priorities. The LHIN may also look for trends

1 . Details on how to complete each section of the Short Form are provided on the following pages. Please contact QIP@ohqc.ca for additional questions. 2. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.

across organizations within their geographic area to identify, share and support the advancement of system-level strategies where a larger system-wide perspective may be appropriate (e.g. transitions of care). The Public The Act requires that every year, health care organizations make their QIP available to the public. Information on how to make the QIP available to the public is described below. Responsibilities within the hospital The diagram below shows the various responsibilities within the hospital and how they may contribute to the development of a QIP.

Hospital Board Because the board is accountable for hospital governance, the Chair of the hospital board is encouraged to certify (via accountability sign-off section of the QIP) that it fulfills the requirements of the ECFAA. Hospital Quality Committee The Quality Committee is required, under the ECFAA, to oversee the preparation of the annual QIP. In addition to this oversight role, Quality Committees may be engaged by their organizations to provide regular (i.e. quarterly) updates on the status of the QIP, the planned initiatives, and progress. The Chair of the Quality Committee is encouraged to certify (via accountability sign-off section) that the organizations QIP fulfills the requirements of the ECFAA. Please see ontario.ca/excellentcare for more information on the role of the quality committee, and its relationship with the Medical Advisory Committee. Chief Executive Officer/ Hospital Administrator The Chief Executive Officer/Hospital Administrator is an integral member of the Quality Committee, and it is recommended that he or she assist with the development and oversee the preparation of the annual QIP. In addition, the CEO is encouraged to certify (via accountability sign-off section) that the organizations QIP fulfills the requirements of the ECFAA.

Development and Submission Process:

The ECFAA defines an organization as a hospital within the meaning of the Public Hospitals Act and as a result, multi-site organizations need only submit one plan for the corporation. Organizations with existing Quality Improvement Plans Organizations with existing QIPs are encouraged to use these plans to populate the QIP Short Form. The short form consists of a word document and an accompanying excel file. Once completed, both files must be submitted to the OHQC by April 1, 2011 by emailing QIP@ohqc.ca. Organizations without existing Quality Improvement Plans: For organizations without existing plans, the QIP Short Form has been designed as a sample template based on leading practice to help them meet their legislative requirements, and also to use for internal quality improvement activities. The short form consists of a word document and an accompanying excel file. Once completed, both files must be submitted to the OHQC by April 1, 2011 by emailing QIP@ohqc.ca. In both cases, the following diagram illustrates the recommended QIP development and submission process:

Reporting to the OHQC: On or before April 1, 2011, every organization must submit the completed QIP Short Form (word document and excel file) to the OHQC by emailing QIP@ohqc.ca. The OHQC will then start a review process to aid in comparative analysis over the 2011/12 fiscal year. Public Posting: Every fiscal year, organizations are required to make their QIP available to the public. The 2011/12 QIP must be available to the public by April 1, 2011. Hospitals should post the full QIP Short Form (both the word document and the accompanying excel spreadsheet) on their website. They may also include other related documents if they wish.

C. Content Guidance
Part A: Overview of Our Hospitals Quality Improvement Plan
This section is a brief description of an organizations QIP. It provides a framework for the organization to express what its quality improvement aims, objectives and initiatives are for the next year. The narrative should be short (2 pages maximum) and easy to follow. For more information, please see Appendix D.

Part B: Our Improvement Targets and Initiatives

The Improvement Targets and Initiatives Spreadsheet http://www.health.gov.on.ca/en/ms/ecfa/pro/updates/ qualityimprov/qip_spreadsheet.xls is an excel file that should be completed to show the improvement targets and initiatives that are part of the QIP. It has been designed with: Flexibility for organizations to add hospital-specific and regional priority areas and measures; and  A core set of indicators to permit province-wide comparison and reporting. 
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Please remember to include this spreadsheet as part of the QIP Short Form package for submission to the OHQC (QIP@ohqc.ca), and post this material publicly. 1.Columns The columns of the QIP Short Form are described below. There are three sections: AIM (columns A-B) - What are we trying to accomplish
Quality dimension The template has been organized into four quality dimensions for ease of use and streamlined provincial and public reporting: Safe, Effective, Accessible, and Patient-Centred. This is the objective of the improvement initiative. For examples of effective aim statements, visit: http://www.ohqc.ca/en/defining_project.php

Objective

MEASURE (columns C-F): How will we know that change is an improvement

Outcome Measure(s)/Indicator(s) This column has been pre-populated with the core set of recommended indicators (see Appendix B). It is recommended that additional indicators be added for each of the quality dimensions (by adding rows to the table) to address organizational priorities. For examples of other measures to add, see Appendix C. Current Performance Performance Goal 2011/12 Priority What is the organizations current performance data or rate associated with the outcome measure? For the core indicators, a specific timeframe is indicated. This column should indicate the outcome the organization expects to achieve by the end of the year. Though it is implied that all of the objectives defined within the QIP are organizational priorities, the priority level further refines the importance of key indicators. The change section, describing the organizations high-level improvement plan, is only required for high priority indicators (indicated as Priority 1). It is recommended that indicators be prioritized based on the following 3 criteria. 1 highest priority:  current performance below benchmark (if one exists) or below long term goal; significant improvements required or improvement initiatives underway.  aligned with organizational priorities/strategic plan  defined accreditation priority or recommendation  funding tied to initiative  aligned with government agenda 2- moderate priority:  current performance just below benchmark (if one exists) or below long term goal; room for improvement  aligned with organizational priorities/strategic plan  defined accreditation priority or recommendation  funding tied to initiative  aligned with government agenda 3- lower priority:  current performance at/above benchmark, provincial rate or long term goal  organizational priority

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CHANGE (columns G-K): What changes can we make that will result in improvement? Note: this section is only to be completed for indicators that have been assigned as Priority 1 (column F)
Improvement initiative The Improvement initiative column provides details about the quality improvement initiative (i.e. the changes) being put in place that will lead to the improvement being sought. Depending on the priority level assigned, objectives may not have detailed improvement initiatives listed for all indicators. At a minimum however, organizations are to complete the change section for all Priority 1 indicators. Methods and results tracking This column identifies how the organization will be tracking its success on process measures related to the indicators tied to the QIP. There should be a general statement included on what the organization is doing to track its improvement, as well as more specific data or targets related to the high level improvement plan. This is the organizations target for 2011/2012. In some cases, the target will be the same as the value established in the Performance goal column. In other cases, targets can be set based on the processes/initiatives laid out in the Improvement initiative column. Organizations should aim to review their existing data over time to set reasonable and appropriate targets. For more information about setting targets, refer to Appendix A Target Justification As described in the legislation, organizations are required to justify their annual performance improvement targets. This can include explaining whether the target is based on research literature, best practice, provincial or other defined benchmarks, scientific evidence, or an internal organizational targeting exercise. This is the place for any additional comments about the initiative. These may include success factors or additional information which may assist the OHQC in understanding the improvement objective.

Target for 2011/12

Comments

2. Rows A number of recommended core indicators within each of the four quality areas have been identified to permit province-wide comparison of and reporting by the OHQC. 1. Safety (hospitals are requested to choose at least one): CDI, VAP, Hand Hygiene, CLI, Pressure ulcers, falls 2. Effectiveness: HSMR, Readmission, ALC, Total Margin 3. Access: ER wait times 4. Patient Satisfaction: Patients who would recommend the hospital to others These core indicators (see Appendix B for more information) were identified based on the following principles: Compliance with the ECFAA  General applicability across sector  Supports standardization  Strategically aligned and focused  Easily understood by the public  Flexible enough to accommodate hospital-specific priorities  Simple and brief 
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Some of the core indicators listed may require a system-level approach before real improvements can be made (e.g. reducing ALC days is partly dependent on long-term care and home care). However, wherever possible, hospital-level change activities should be identified so that progress can be achieved in improving the performance of the indicator within the organization. It is also encouraged that hospitals work with other partners across the LHIN to improve system-level indicators such as ALC and readmission.

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Not all of the core indicators are relevant to all hospitals. For example, for hospitals that do not meet the reporting threshold for HSMR, this indicator should not be completed. Similarly, hospitals that do not treat complex continuing care patients do not need to complete the indicators for pressure ulcers. Other indicators may not be relevant to some hospitals at this time, but over the next two years will become increasingly important (such as data from patient and employee surveys). It is recommended that wherever possible, hospitals add similar indicators to the ones listed that are relevant to their patient populations. In addition to the core indicators (see Appendix B for more information), organizations should identify other priority indicators within each of the four quality dimensions to include in their QIP. Equity is another key attribute of quality, and although it is not explicitly referenced in the QIP Short Form, hospitals are encouraged to incorporate it in their QIP as a strategy for improvement. Suggestions can be found in Appendix C.

Part C: The Link to Performance-based Compensation of Our Executives

ECFAA requires that the compensation of the CEO and other executives be linked to the achievement of performance improvement targets laid out in the QIP. As executive compensation is to be tied to the QIP, organizations are expected to include a performance based compensation component of the QIP for the fiscal year beginning April 1, 2011. Organizations need to ensure that compensation for the following executives is linked to the organizations achievement of the targets set out in their annual QIPs: CEO (Administrator)  Chief of Staff  Chief Nursing Executive  Senior Management reporting directly to CEO (or person with position equivalent to CEO) 
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The QIP Short Form (Part C) requires organizations to identify the manner in and extent to which executive compensation is linked to performance. The legislation and regulations do not include specific requirements regarding the percentage of salary that should be subject to performance-based compensation, the number of targets that should be tied to executive compensation, weighting of these targets, or what the targets should be. These are decisions that should be made by the organizations Board of Directors and senior management team. For more information about performance-based compensation, refer to Appendix E or the update on Performance based compensation at Ontario.ca/excellentcare.

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Part D: Accountability Sign-off

The QIP Short Form includes a section to allow for accountability sign-off (from the Board Chair, Quality Committee Chair and CEO). This will assist organizations in ensuring that their legislative obligations under the ECFAA have been considered during the development of the QIP. While this is not a legal requirement under ECFAA, it is recommended as a best practice. More specifically, the Board Chair and Quality Committee Chair are asked to certify that the QIP has been informed in part by: A. The patient relations process; B. Patient and employee/provider surveys3; C. Aggregated critical incident data; and D. I nformation concerning indicators of the quality of health care provided by the organization pursuant to regulations made under the Public Hospitals Act. The sign-off also certifies that the QIP contains: Annual performance improvement targets;  Target justifications; and  Information concerning the manner in and extent to which executive compensation is linked to the  achievement of the targets.
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As well, the sign-off certifies that the QI plan was reviewed as part of the planning submission process and is aligned with the organizations operational planning.

3. It should be noted that patient and employee/provider surveys do not need to be initiated until April 1, 2011 and April 1, 2012 respectively.

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Appendix A: Quality Improvement 101

Quality improvement is a structured organizational process for planning and executing a continuous flow of improvements to provide quality health care that meets or exceeds expectations.4 Since change/improvement is not always easy to implement, it is important for organizations to identify and prioritize the initiatives that will be most likely to demonstrate the most visible improvements. Over time, organizations invested in quality improvement work have applied a variety of quality improvement approaches, such as Lean, Six Sigma, etc. One very practical and well-established framework to assist organizations with their quality improvement efforts is the Model for Improvement, developed by Associates for Process Improvement.5 The QIP Short Form developed under the ECFAA has been designed to align with the Model for Improvement6 with three essential questions driving the improvement process: 1. SETTING AIMS: What are we trying to accomplish? QI projects should have a clear aim statement that lets the entire organization know what the organization  is setting out to do. The aim statement should have a specific measurable target and a clear time-frame for completion.  The aim statement should describe the target patient population and be relevant to them; in other words,  it should be clear how they will be better off as a result of the improvement. The aim statement should be aggressive enough to enable meaningful change, but at the same time attainable.  The SMART mnemonic summarizes these desired characteristics of an excellent aim statement: 
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S M A R T

Specific Measurable/Meaningful Attainable Relevant/Results oriented Time-bound

2. ESTABLISHING MEASURES: How will we know that change is an improvement? Identify measures that demonstrate whether a specific change led to an improvement.  Use both qualitative and quantitative measures as well as a mix of outcome measures (patient perspective)  and process measures (systems perspective).
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A measure, or indicator, can be defined as7: A. An assessment of a particular health care process or outcome; B.  A quantitative measure that can be used to monitor and evaluate the quality of important governance, management, clinical, and support functions that affect patient outcomes; C.  Measurement tools or screens, used as guides to monitor, evaluate, and improve the quality of patient care, clinical support services, and organizational functions that affect patient outcomes

4. McLaughlin, C and Kaluzny, A. Continous Quality Improvement in Health Care. 1999. 5. http://www.apiweb.org/API_home_page.htm 6.  Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing O Enhancing Organizational Performance. 7.  Mainz, J. Defining and classifying clinical indicators for quality improvement. International Journal for Quality in Health Care. 2003. Volume 15. Number 6. Pp. 523-530.

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Outcome Indicators: The voice of the patient. Outcome measures reflect the effect of care processes on the health of patients/ population8. They represent the bottom line to the patient: am I happier, feeling better, or likelier to live longer as a result of the care being provided?9 Process Indicators: The voice of the system. Process indicators assess what the provider did for the patient and how well it was done. Process indicators are especially useful when quality improvement is the goal of measurement. 10Process measures check whether or not some process or activity which has been shown to have a positive impact on outcomes is actually being done. Health care providers are particularly interested in processes because they answer the question: am I doing all the things Im supposed to be doing to improve health for my patients.11 Both types of indicators are equally important since elements of the process of care do not signify quality until they are validated by demonstrating their relationship to desirable outcomes. (Mainz) 3. SELECTING CHANGES: What changes can we make that will result in improvement? Organizations can select from a wide variety of different ideas for improvement identified in the literature or by quality improvement organizations. The OHQCs Quality Monitor report contains ideas for improvement and best practice stories for all of the core indicators in the plan as well as many other areas. Organizations can also consult the saferhealthcarenow.ca website for ideas.
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 Not all changes result in improvement, and not all ideas from other hospitals can be adapted to local settings. It is important for organizations to first understand the root causes of quality problems in their own setting, and then tailor their strategies to address those causes. This will help organizations to prioritize and identify the types of activities/changes most likely to result in significant improvement.

4. TARGET SETTING Organizations are free to set whichever targets they wish. Different hospitals will have different priorities, and local factors will also influence the targets that are set. The following are ideas and suggestions to help guide this process. A. V  AP and CLI: evidence suggests zero is possible. Many hospitals have already attained this threshold (for example, most ICUs in Michigan under a state-wide initiative). Organizations already at zero or approaching zero may wish to set a target of zero. Organizations which are significantly above the average may wish to consider an interim target of decreasing the rate by half in 2011/12, and then eliminating them by 2012/13. B. H  SMR: it would not be prudent to suggest a numeric target because the measure was designed to help a hospital compare itself against a previous baseline, rather than to compare between different hospitals. Instead, hospitals may wish to consider targets that constitute improvement compared to previous results. Consider aiming for a 5 to 10 point decrease compared to the baseline year (2009/10). Organizations with HSMRs currently over 100 may wish to consider targets at the aggressive end of this range. Many hospitals in Ontario have achieved improvements of this magnitude in the past, and some have done even better. Note that some hospitals HSMR may have increased in 2009/10 compared to previous years; in such instances, a hospital may wish to consider a target based on improving on its previous best year.

8. ibid. 9. http://www.ohqc.ca/en/measurement_tools.php 10.  Mainz, J. Defining and classifying clinical indicators for quality improvement. International Journal for Quality in Health Care. 2003. Volume 15. Number 6. Pp. 523-530. 11. http://www.ohqc.ca/en/measurement_tools.php

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 e caution that the uncertainty and variability around a hospitals HSMR in any given year is typically large (for W Ontario hospitals, there is a typical range of 5 to 12). This means that the HSMR could drop by five points by pure chance even if no improvements took place. It may take more than one year before a statistically significant improvement can be detected. Thus, if an organization wants to report a target of a five point reduction for the coming fiscal year (2011/12), it may want to state in the verbal section that this goal is part of a longer-term plan for reduction (e.g. 15 points over three years), where the statistical significance of the larger reduction can more likely be confirmed. C. T  otal Margin: The ideal for this indicator is 0% - in other words, revenue equals expenses in a given year (excluding the impact of facility amortization). Hospitals are encouraged to describe, in their change ideas, clinically focused strategies that both improve quality and contain or reduce costs in order to maintain a balanced budget. See Appendix C for examples. D.  ED wait time: Two options have been provided below. Hospitals may develop change plans for either of these indicators, depending on local priorities. Depending on local factors, current performance and the extent to which important ideas for improvement have yet to be implemented, hospitals may wish to choose any of the following guidelines in setting targets for the next year: Aim to match those with current best results  Aim to match provincial average, if significantly far from average  Aim for a rate of reduction comparable to the province-wide annual reduction in this indicator 
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E. P  atient experience: The current provincial average for patients definitely recommending the hospital to friends and family is 74%. Leaders in North America have attained rates of in the 85-90% range.12

12. Visit hospitalcompare.hhs.gov in the USA. Examples include Massachusetts General (88%), Brigham & Womens (87%), Mayo Clinic (84%).

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Appendix B: Indicator definitions and technical information

The following recommended core indicators are included in the QIP Short Form.
Quality dimension Safety Core Indicators Definitions Technical Information

There are many different aspects of patient safety in hospitals, including hospital acquired infections, missed diagnoses, medication errors, avoidable surgical complications or errors, avoidable thromboembolisms, and avoidable injuries. At present there is no single big dot indicator in Ontario that encapsulates all of these different aspects of safety. We recommend that organizations include in their QIPs at least one indicator from the following list of standardized indicators. Hospitals may choose more than one of these indicators: Clostridium Difficile Infection (CDI): CDI rate/1,000 patient days (January December 2010)) CDI rates are determined by the number of patients newly diagnosed with hospitalacquired CDI, divided by the number of patient days in that month, multiplied by 1,000. Patient days are the number of days spent in a hospital for all patients. VAP rates are determined by the total number of newly diagnosed VAP cases in the ICU after at least 48 hours of mechanical ventilation, divided by the number of ventilator days in that reporting period, multiplied by 1,000. Ventilator days are the number of days spent on a ventilator for all patients in the ICU 18 years and older. The number of times that hand hygiene was performed before initial patient/patient environment contact divided by the number of observed hand hygiene indications for before initial patient/patient environment contact multiplied by 100. CLI rates are determined by the total number of newly diagnosed CLI cases in the ICU after at least 48 hours of being placed on a central line, divided by the number of central line days in that reporting period, multiplied by 1,000. Central line days are the number of days spent on a central line for all patients in the ICU 18 years and older. Percentage of complex continuing care residents with new pressure ulcer in the last three months (stage 2 or higher) See http://www.health.gov. on.ca/en/pro/programs/ris/docs/ cases_of_clostridium_difficile_ infections.pdf To calculate baseline for 2010, take the average of the monthly rates reported from January 2010 to December 2010 (see Patient Safety Indicators website) See http://www.health.gov. on.ca/en/pro/programs/ris/docs/ cases_of_ventilator_associated_ pneumonia.pdf To calculate baseline for 2010, take the average of the quarterly rates reported from January 2010 to December 2010 (see Patient Safety Indicators website) See Patient Safety Indicators website

Ventilator Associated Pneumonia (VAP) VAP/1,000 ventilator days (January December 2010)

Hand Hygiene compliance before patient contact (2009-2010 data as of April 30, 2010)

Central Line Associated Blood Stream Infection (CLI) CLI//1,000 central line days (January December 2010)

To calculate baseline for 2010, take the average of the quarterly rates reported from January 2010 to December 2010 (see Patient Safety Indicators website)

Pressure Ulcers (CCRS, FY 2009/10)

See http://www.health.gov. on.ca/en/pro/programs/ris/docs/ decubitus_pressure_ulcers.pdf

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Quality dimension

Core Indicators Falls (CCRS, FY 2009/10)

Definitions Percentage of complex continuing care residents who do not have a recent prior history of falling, but fell in the last 90 days

Technical Information

Effectiveness Hospital Standardized Mortality Ratio (HSMR)13 (2009-2010 data as of December 2010) Number of observed deaths divided by the number of expected deaths, multiplied by 100 and based on diagnosis groups that account for 80% of all deaths in acute care hospitals and adjusted for other factors affecting mortality, such as age, sex, and length of stay Readmission within 30 days for selected CMGs to any facility Consistent with H-SAA reporting. This data will be provided to hospitals via FIM in mid-February Consistent with H-SAA reporting. See http://www.health.gov. on.ca/en/pro/programs/ris/docs/ alternate_level_of_care_days. pdf. It is requested that hospitals provide the methodology for calculating this indicator to the OHQC when the QIP is submitted. Consistent with H-SAA reporting. See: http://www.health.gov.on.ca/en/ pro/programs/ris/docs/hospital_ total_margin.pdf

30 day readmission rate to any facility (specific Case Mix Groups) (Q1 2010/11) % ALC days (DAD, CIHI) (Q2 2010/11)

Total number of inpatient days designated as ALC, divided by the total number of inpatient days

Hospital - Total Margin (OHRS)14 (Q3 2010/11)

Percentage by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expense, excluding the impact of facility amortization, in a given year

Access

Two options have been provided below. Hospitals may develop change plans for either of these indicators, depending on local priorities. 90th percentile ER Length of Stay for Admitted Patients (NACRS, CIHI) (Q3 2010/11) 90th percentile ER length of Stay for Complex Conditions (NACRS, CIHI) (Q3 2010/11) 90th Percentile ER length of stay for Admitted patients (ER length of stay is defined as the time from triage to registration, whichever comes first, to the time the patient leaves the ER.) 90th percentile ER Length of Stay for Complex conditions /requiring more time for diagnosis, treatment or hospital bed admission (Refers to the maximum amount of time 9 out of 10 patients with complex conditions requiring more time for diagnosis, treatment or hospital bed admission spent within the ER from the time they register to the time they leave the ER) Consistent with H-SAA reporting. See http://www.health.gov. on.ca/en/pro/programs/ris/docs/ er_los_for_admitted_patients.pdf Consistent with public reporting.
http://www.health.gov.on.ca/en/ See http://www.health.gov. on.ca/en/pro/programs/ris/docs/ public/programs/waittimes/edrs/ er_los_for_complex_patients.pdf default.aspx

and http://www.health.gov.on.ca/en/ public/programs/waittimes/edrs/ default.aspx

13.  All hospitals which are currently large enough to report publicly on HSMR are requested to include it in their quality improvement plans. Individual hospitals which are not large enough to report publicly (do not meet the threshold of 2,500 HSMR cases) do not need to include HSMR in their plan. 14.  Options are being explored around measures of clinical efficiency for inclusion as core indicators in future quality improvement plans. Hospitals are encouraged to describe, in their change ideas, clinically focused strategies that both improve quality and contain or reduce costs in order to maintain a balanced budget. See Appendix C for suggestions.

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Quality dimension Patient Centred

Core Indicators

Definitions

Technical Information

Patient satisfaction indicator

Please choose the question that is relevant to your hospital: NRC Picker / HCAPHS: Would you recommend this hospital to your friends and family? In-house survey: provide the percentage response to a summary question such as the Willingness of patients to recommend the hospital to friends or family Most hospitals use NRC Picker for both hospital in-patients and emergency department (ED) patients. Hospitals may choose to select the in-patient version of the indicator, ED version of the indicator, or both indicators in their plan, depending on where they see the greatest areas for improvement. Hospitals that do not treat these patients can use patient satisfaction data from other patient care areas as applicable.

Numerator: # of respondents who responded Definitely Yes (HCAHPS) or yes, definitely (NRC Picker) Denominator: # of respondents who registered any response to this question (no not include non-respondents) Please list the question and the range of possible responses when you return the QIP. For both options, take the average across all survey responses collected from the most recent consecutive 12-month period (for most hospitals, this will be Oct 2009 to Sept 2010). If hospitals do not currently include this question in their patient satisfaction survey, it is recommended that it be included in future surveys.

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Appendix C: Examples of other indicators to include in the QIP

In addition to the core indicators set out above, organizations should identify other priority indicators to include in this plan. Different hospitals will have different priorities, and their QIPs and targets should reflect this variation. Below are some suggestions: SAFETY 1) Critical Incidents Organizations need to review the aggregated critical incident data when developing the QIP. Based on regulations under the Public Hospital Act, the Quality Committee will receive aggregated critical incident data (from the administrator) at least twice per year, with data about all critical incidents occurring at the hospitals. For ease of reporting and interpretation, organizations may wish to aggregate critical incident data by incident types (i.e. medication, surgical process, clinical administration, medical device etc.) to identify the specific focus/area for improvements within the QIP. For more information, including guidelines for critical incident reporting, please see the latest update on critical incident reporting. For example, if a large proportion of the organizations aggregated critical incident data is medication-related incidents, a hospital may identify a medication safety improvement initiative and indicator (i.e. medication reconciliation at transfer) within its QIP. However, if upon analysis it appears that a large proportion of all incidents relate to documentation and/or communication failures, organizations may identify objectives and indicators to make improvements in these related processes. 2) Required Organizational Practices High priority action items and Required Organizational Practices highlighted through the accreditation process may also be worthwhile addressing and including within the QIP. The list below are just a few examples: A. Suicide prevention B. VTE prevention C. Medication Reconciliation 3) Hospital Acquired Infections (HAI) Although hospitals have been reporting publicly on a number of hospital acquired infections, not all of these indicators are part of the core set in the template. However, improvement initiatives may be underway for other indicators (i.e. MRSA, VRE), and hospitals may consider including these as well. 4) Safety Culture The ECFAA requires organizations to consider results from the employee/service provider surveys in the development of their QIPs. Organizations are encouraged to include survey data (including data relating to employee/service provider safety) as well. EFFECTIVENESS 1. Total margin: Hospitals are encouraged to describe, in their change ideas, clinically focused strategies that both improve quality and contain or reduce costs in order to maintain a balanced budget. This could include: Measuring and reducing inappropriate hospitalizations. Many hospitals use tools like MedWorxx or Interqual to  monitor admissions which do not meet criteria for acuity of the admission. Reducing unnecessary repeat lab tests or diagnostic imaging  Reducing inappropriate use of drugs  Also, hospitals can acknowledge that work on safety or effectiveness in the areas above can help reduce  costs. This includes reducing VAP, CLI, pressure ulcers and readmissions.
g g g g

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2. Employee and Physician surveys: As stated above, the ECFAA requires organizations to consider results from the employee/service provider surveys in the development of their QIPs. Where possible, organizations are encouraged to include survey data in the QIP. 3. Compliance with best practice guidelines: A.  Percentage of patients discharged for acute coronary syndrome compliant with all (16) best practice guidelines. (Approximately 20 hospitals are already reporting this information internally, using the Guidelines Applied in Practice (GAP) tool in collaboration with Ottawa Heart Institute). B. Percentage of patients with other conditions discharged with guideline-recommended drugs and tests. 4. Sepsis mortality rate: Effective early recognition, screening, timely antibiotics and control of blood pressure and blood sugar can reduce this major cause of mortality. 5. Prophylaxis for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE): Percentage of surgical patients with DVT or PE, or percentage of eligible patients who receive adequate prophylaxis for these conditions. This is one of the major causes of avoidable mortality and morbidity in hospitals. ACCESS 1. Wait times: In addition to Emergency room wait times, organizations could include other indicators from Ontarios Wait time strategy, such as wait times for surgery, CT or MRI. Hospitals can choose specific procedures of interest, and can use either 90th percentile overall wait time, or percentage of patients who meet the target wait time for their priority category. Both are found on the Ministrys public reporting website and both are acceptable. However, the OHQC notes that the latter has one particular advantage: it highlights the problem that for most surgical procedures, high priority patients are far less likely to have their surgery done within the target time frame than those at lower priority. For example, the percentage of priority 2 cases done within the target time is 60% for cancer, 45% for neurosurgery and 68% for orthopaedics. Use of overall 90th percentile wait time tends to obscure this problem altogether. 2. Equity: Equity is a key attribute of quality, and although it is not explicitly referenced in the QIP Short Form, hospitals are encouraged to incorporate it in their QIP as a strategy for improvement. For many hospitals, the ability to improve in a particular area may depend on how well services are tailored to more vulnerable groups or those with special needs (e.g. low income, low education or those with language barriers). Often, the room for improvement in patient care is greatest for these groups. For example, a hospital may aim to reduce readmissions for selected conditions by 10% overall, but also aim to reduce readmissions by 15% for those who reside in certain low-income neighbourhoods or those with no fixed address. Change ideas include simplified patient teaching materials for those with low literacy, improved access to translators, early case management to address the individuals more complex non-medical needs, and ensuring access to more intensive support services in the home (e.g. homemaking) for those who are socially isolated. PATIENT-CENTREDNESS 1. Patient Experience: Organizations need to review the results from the patient/caregiver surveys in the development of their QIP. Organizations should review this data to identify if there are areas for improvement that should be included in their QIP. More detailed indicators that could be added include: A. Percentage response on any individual question of particular concern to a hospital B. Percentage of patients who received all the information they needed when they left hospital/ED For more information on patient surveys, please see ontario.ca/excellentcare.

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2. Patient Relations Process: Organizations need to review data relating to the patient relations process in the development of their QIP. Organizations should review this data to identify if there are areas for improvement that should be included in their QIP. Possible indicators for the patient relations process that could be included are: Number of pre-emptive calls  Number of inquiries, supports, suggestions, comments received from patients, staff and physicians  Number of complaints/compliments  Number of patients expressing concerns divided by number of surveys received in a particular quarter (per  cent of patients reporting a negative comment) Distribution of complaints in pre-defined categories  Method of complaints (telephone, letter, in-person, email, etc.)  Source of complaints (inpatient versus outpatient)  Severity of complaints  Resolution time 
g g g g g g g g g

Further information on the Patient Relations Process will be provided in winter 2011. 3. Other indicators of patient-centredness: Some common areas where patient experience scores indicate that problems may exist include: Pain control  Responsiveness (e.g. response to a call bell)  Communication  The percentage of patients who get all the information they need when they leave. Patients must answer  positively on a full series of questions in order to have counted as having all information needed. The provincial average for this indicator is around 25% and improvements in this indicator could help reduce readmissions and adverse events after discharge.
g g g g

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Appendix D: Guidance on designing Overview of Our Hospitals Quality Improvement Plan (Part A)
Quality Improvement Plans should be seen as a tool that communicates a structured format and common language that focuses organizations on change. The change plans that result from a QIP are the most critical element of a quality improvement initiative. The QIP should guide the design of change plans and facilitate dialogue to support continuous quality improvement processes. This section is a brief description of an organizations QIP and provides organizations with a framework to express what their quality improvement aims, objectives and initiatives are for the coming year. The narrative should be brief (2 pages maximum) and easy to follow. To help organizations construct the narrative, a framework has been developed that has four sections: 1. O  verview: A general statement that is inspiring and situates the objectives within the Vision, Mission and Values of the organization. 2. F  ocus: A description of the objectives that have been identified to improve quality of services and care in the hospital. This section describes the specific aims, measures and change ideas that form the core of the plan. Organizations should also indicate how resources will be used to ensure that the correct financial levers are in place to execute the activities listed in the QIP. 3. A  lignment: An explanation of how this document links to the other planning documents developed by the organization and key external partners such as the LHIN and CCACs. 4. C  hallenges, Risks and Mitigating Strategies: this section describes any existing risks that may threaten accomplishment of the objectives and the mitigating strategies that have been identified to lower those risks. The measurement challenges already identified in the materials within this package do not need to be restated here. 1: Overview of our quality improvement plan for 2011-12 What is required in this section is a brief (100 word maximum) description of the quality goals or statements that describe the organizations overall vision for quality in the next year. The overview should be written in plain language and describe how patients will notice that their experience specifically the care they are receiving has improved. An effort should be made to make this statement inspiring for staff and reassuring for the people you serve. Ideas include: 1. Patients with complex conditions will wait one hour less in our emergency department 2. We will reduce avoidable harm from adverse events by one half in our hospital in the next year 3. We will match the best results in Ontario for wait times in large hospitals. 2: Focus: What we will be focusing on and how these objectives will be achieved This section should describe the specific aims, measures and ideas for improvement that your organization will put in place. They should be described in a plain English, with abbreviations or complex terms defined. When describing ideas for improvement, go beyond generic statements about teamwork or consultation. Talk about specific evidence-based organizational or clinical best practices or different models of care or care delivery that the organization wants to implement, as well as any investments (in staff, staff training or technology) that support those goals.

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3. Alignment: How the plan aligns with the other planning processes It is important to situate the QIP as one component of the hospitals broad strategic aims and objectives. While the QIP is a critical component of a hospitals strategic and operational planning, it does not in itself communicate everything the hospital is doing. Instead, it is one component of the hospitals overall planning. A high performing organization combines and integrates a strategic plan, a Hospital Service Accountability Agreement (H-SAA), and the QIP. Organizations can also consider describing how the QIP aligns with accreditation, university-wide plans (for academic centres) and LHIN-wide improvement plans, particularly in the areas of ED, ALC and readmissions. The integration of these pieces helps ensure financial responsibility, accountability to patients, and high quality care. 4: Challenges, Risks and Mitigating Strategies This section highlights the things that need to happen for change to occur, and the challenges that may exist that could prevent that change from happening. It is a realistic view of what needs to be put in place or what needs to be altered in order for success to be achieved. It also provides an opportunity to explain the use the hospital makes of its limited resources, and to demonstrate that that the QIP is part of or linked to the hospitals operating plan and the H-SAA. Although the QIP does not include information related to financial efficiency, indicators for total margin and current ratio are included in the H-SAA and it is recommended that hospitals provide links to this information in the introductory section of the QIP (Part A - Narrative).

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Appendix E: Guidance on performance based compensation

Excellent Care for All Act Guidance materials
Performance Based Compensation and the Quality Improvement Plan The ECFAA requires that the compensation of CEOs and other executives be linked to the achievement of performance improvement targets laid out in the quality improvement plan (QIP) of every health care organization (beginning with hospitals) in Ontario. As executive compensation is to be tied to the QIP, organizations are expected to include a performance-based compensation component as part of the QIP for the fiscal year beginning April 1, 2011. A description of the manner in and extent to which executive compensation is tied to performance must be included in the QIP and available to the public. This can be described in the QIP in a number of ways. This document is designed to assist organizations in describing the manner in and extent to which they are tying executive compensation to targets set out in their QIPs. It does not describe best practices for developing performance-based compensation plans in general, as this is a larger undertaking that extends beyond the purview of ECFAA. A regulation describing the definition of executive under ECFAA has been filed and came into effect January 1, 2011. Purpose of Performance-based compensation: The purpose of performance-based compensation related to ECFAA is to drive accountability for the delivery of quality improvement plans. Performance-based compensation can help organizations to achieve both short and long-term goals. By linking achievement of goals to compensation, organizations can increase the motivation to achieve these. Performance-based compensation will enable organizations to: 1. Drive performance and improve quality 2. Establish clear performance expectations 3. Create clarity about expected outcomes 4. Ensure consistency in the application of performance incentives 5. Drive transparency in the performance incentive process 6. Drive accountability with respect to the delivery of the Quality Improvement Plan 7. Enable team work and a shared purpose Organizational positions to which performance-based compensation applies: As per regulations, compensation for the following executives should be linked to their organizations achievement of quality improvement targets set out in their annual Quality Improvement Plans: CEO (Administrator)  Chief of Staff  Chief Nursing Executive  Senior Management reporting directly to CEO (or person with position equivalent to CEO)..... 
g g g g

Organizations should clarify which individuals make up the senior management team. One way to do this is by establishing formal terms of reference for the senior management team. This is important so that it is clear which individuals are defined as executives with respect to performance-based compensation.

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Describing the manner and extent to which compensation is linked to performance The QIP Short Form (Part C) requires organizations to identify the manner in and extent to which their executive compensation is linked to performance. The legislation and regulations do not include specific requirements regarding the percentage of salary that should be subject to performance-based compensation, the number of targets that should be tied to executive compensation, weighting of these targets, or what the targets should be. The following recommendations have been provided to guide organizations in completing this section of the QIP: 1) Outcome vs. process: Executive compensation should be tied to outcome measures (or using quality improvement vocabulary, Big Dot measures) that are directional and focus on outcomes rather than process to communicate the overall change being undertaken. 2) SMART: When setting performance improvement targets, it is essential to establish S.M.A.R.T. (specific, measurable, achievable, relevant and time-bound) performance objectives. 3) Focused: Each executives compensation should be tied to no more than 6-8 targets maximum. This includes other targets (outside of the QIP) that may be part of a larger compensation plan15. If there are too many objectives, it will be difficult for executives to focus on all of them. 4) Meaningful: In order for a performance-based compensation plan to be motivating, it generally should involve a meaningful portion of the executives base salary. The amount determined depends on the organizations existing circumstances. It should be based on industry-leading practices and should be determined by the Board. 5) Relevant: Organizations choose targets under the Annual Quality Improvement Plan to which executives have a direct link. Performance-based compensation is most effective when incumbents feel they have clear control over outcomes. Organizations may choose to use different performance targets for different executives to best align targets with individual executives particular scope of work. 6) Gradual: Organizations introducing performance-based compensation for the first time should initially link targets to realistic and achievable goals, while phasing in stretch targets16 over time. Phasing in higher levels of performance pay also enables Boards and plan participants to evaluate, modify and become more comfortable with this type of compensation plan 7) Inclusive: Targets from each of the strategic areas of the QIP (safety, effectiveness, access, and patient-centred) should contribute to the performance-based compensation plan to ensure accountability in all these areas15. 8) Range approach: Having a plan that recognizes different levels of performance achievement (threshold, target and maximum) allows for more aggressive target setting and helps articulate the objectives that need to be achieved to receive performance-based pay. This is in contrast to an all-or-nothing approach where individuals are compensated only if targets are achieved. 9) Long-term and strategic: In order to encourage consistent behaviour throughout the organization, it is recommended that organizations use their strategic plan as a starting point for setting performance improvement targets. This will ensure that executives are encouraged to achieve objectives that are aligned with the organizations long-term strategic directions.

15.  Some organizations may have a larger, more comprehensive compensation plan that includes targets separate from those included in the QIP. Organizations are not limited to including only quality targets in their performance based compensation plans, but these quality targets must have a prominent role in determining performance based compensation. 16. A measure or goal that is at the top limit of the range of expected performance outcomes. 17. Note that this level of detail is for internal processes and does not need to be included in the QIP and posted publicly.

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10) Documented: Health care organizations should develop documentation17 that clearly articulates the manner in and extent to which executive compensation is linked to the targets set out in the QIP. Documentation should include: Explanations of how performance targets were chosen  Individuals included in the performance-based compensation plan  The target size of performance-based pay, as well as threshold and maximum payout levels  The basic level of performance that needs to be achieved in order for a payout to occur  Timing of payouts  Description of the manner and extent to which compensation is linked to performance  Any other relevant plan details. 
g g g g g g g

11) Monitored over time: Organizations should monitor target-setting vs. actual payouts, to help determine whether the incentive plan design was in fact effective. If over a few years executives are reaching maximum performance on all their quality improvement targets, this may signal that targets need to be re-calibrated going forward. Connection between ECFAA and the Public Sector Compensation Restraint Act The Excellent Care for All Act (ECFAA) works in conjunction with the Public Sector Compensation Restraint to Protect Public Services Act, 2010 which provides that the rate of pay in effect on March 24, 2010 for hospital employees who do not bargain collectively cannot be increased until April 1, 2012, subject to certain exceptions. Where an executive compensation plan does not provide for payment based on assessment of performance, hospitals must ensure that the executive compensation plan is modified to be compliant with the ECFAA. This means that the payment of a portion of the executives existing compensation must be made contingent on the achievement of the performance improvement targets set out in the annual QIP, without increasing the actual or potential compensation available to the executive on March 24, 2010.

Examples of linking compensation to the QIP

Under the ECFAA, organizations are required to ensure that the payment of compensation is linked to the achievement of the performance improvement targets set out in the QIP. A description of the manner in and extent to which executive compensation is tied to performance must be included in the QIP and available to the public. This can be described in the QIP in a number of ways. The examples below were derived by reviewing best practices in the field. Hospitals are not limited to using the formats provided Example 1: This example shows the percentage of salary at risk for each individual executive, and the particular set of targets the individual is accountable for achieving. CEO X% of base salary is linked to achieving the targets set our in our QIP on the below indicators Chief of Staff X% of base salary is linked to achieving the targets set our in our QIP on the following indicators Chief Nursing Executive X% of base salary is linked to achieving 100% of the targets set our in our QIP on the following indicators Senior Management X% of base salary is linked to achieving 100% of the targets set our in our QIP on the following indicators

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Indicators: ER Wait times  Pressure ulcers  Patient Satisfaction  30-day readmission 

g g g g

The below Performance allocation plan is used to determine the magnitude of the performance allocation:

Performance Allocation Plan

Progress against Quality and Safety Target Worse than previous year performance and no special considerations Worse than previous year performance *with special considerations % of available incentive 0% Up to 10% *E.g. H1N1, catastrophic failure of systems etc Comments

Maintained previous year performance **and special considerations Better than previous year performance and not met target Achieved Target

Up to 20% Up to 50% Up to 100%

**E.g. baseline affected by unusual circumstances

Example 2: This example shows the unique weighting of each target in the QIP. It also provides specific values that must be reached to obtain the available incentive. For each of our executives, X% of compensation is linked to achievement of targets laid out in the Quality Improvement Plan.

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The below Performance allocation plan is used to determine the magnitude of the performance allocation.
Quality dimension Objective Outcome measure/ indicator Percent of complex continuing care residents with new pressure ulcer in the last three months (stage 2 or higher) Readmission within 30 days for selected CMGs to any LHIN ED wait times: 90th percentile ER length of stay for admitted patients % of patients who would definitely recommend this hospital to friends and family Current performance Target for 2011/12 Weighting % of available incentive

100% Safety Avoid new pressure ulcers State current performance (from Part B of QIP Short Form) State Target (from Part B of QIP Short Form) Show how much each indicator is worth (sum = 100%) Insert Target value (performance score required for 100% payout)

66% Insert performance score that would result in a 66% pay-out

33% Insert performance score that would result in a 33% pay-out

0% Insert performance score that would result in a 0% payout

Effectiveness

Reduce unnecessary hospital readmission Reduce wait times in ED

Access

Patientcentred

Improve patient satisfaction

It should be noted that the examples above are for demonstration purposes only and hospitals are not limited to using any of the formats provided.

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Appendix F: Example of completed row in QIP

EXAMPLE AIM Objective MEASURE Outcome Measure/ Indicator Hand hygiene compliance before patient contact: The number of times that hand hygiene was performed before initial patient contact divided by the number of observed hand hygiene indications for before initial patient contact multiplied by 100 - 2009/10, consistent with publicly reportable patient safety data Current performance 65% Performance goal 2011/12 80% Priority CHANGE Improvement initiative monthly education and training sessions by program Methods and results tracking audit to show 80% of staff trained Target for 2011/12 80% of hand hygiene champions trained Target justification Comments

Improve provider hand hygiene compliance

Complete installation of ABHR outside all remaining patient rooms and treatment areas Positive deviance training for HH champions

environmental review to confirm installation

100% attendance at training. 75% selfreport using a positive deviance technique. Survey patients to ask if they were comfortable doing so; aim for 50%

internal targeting exercise decided to aim for getting halfway towards long-term goal this year and attaining longterm goal in the following year

Encourage patients to ask providers if theyve washed hands using pamphlets, posters.

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