Continuous Quality Improvement Interim Report for Davis Centre
Davis Centre is committed to ongoing and continuous quality improvement.
This report is an interim report for the 2022-2023 fiscal year. Section 168 (6(5, 6)) of the O. Reg. 246/22 of the Fixing Long Term Care Act.
This report was completed on July 6, 2022.
Peel Region’s Long-Term Care (LTC) Division’s Continuous Quality Improvement (CQI) Program is developed to facilitate continuous quality improvements at all levels of the organization.
The CQI program includes processes to monitor, review, and improve quality improvement initiatives and activities in the home to all areas of resident care, safety, satisfaction, and services.
The CQI program provides a framework with structured processes and quality improvement tools and techniques to apply consistently across the division.
The development of the program provides a basis to:
- Facilitate evidenced informed decision making.
- Promote outcome measurement, and
- Create a culture of continuous improvement that includes active engagement and participation from all employees at every level of the division.
What is Continuous Quality Improvement?
Continuous Quality Improvement (CQI) is an organizational philosophy that is strategic in approach.
- Aims to provide the best health care possible.
- Uses innovation to meet residents’ needs and to exceed their expectations by using a structural process that identifies areas of improvement within an organization.
- Shifts the focus from applying interim solutions to reoccurring problems to critically assessing the current processes and practises in place. Provides a common understanding of the underlying causes of gaps in an effort to improve them.
- Encourages employees to seek opportunities for change and to try out ideas on a smaller scale before rolling them out to the entire organization. This ensures that the best possible solution is implemented for the current situation.
Davis Centre is committed to ongoing and continuous quality improvement. This is achieved by having a designate lead for quality improvement who oversees and ensures adherence of the CQI Program at the home.
The designate works with the team to reflect on the practices, programs, and services to support specific quality improvement activities and initiatives.
CQI is a required standing agenda item at every Region of Peel LTC centre and departmental team meeting.
Name of Designated Lead for Quality Improvement Initiatives at Davis Centre: Lennie Iskender
Position of the Designated Lead: Administrator
Peel Region owns and operates 5 long-term care homes: Davis Centre, Sheridan Villa, Malton Village, Tall Pines, and Peel Manor.
We use innovative and person-centered approaches to meet the complex clinical and emotional care needs of our residents.
These approaches emphasize quality, emotion-based care, and engaging every resident in unique and personally meaningful ways.
For example, Peel Region was the first organization in Ontario to apply the Butterfly model of care. This model creates a home-like environment, works to stimulate positive memories, and promotes connection between residents and employees.
Since 2017, the Region of Peel has been working to implement the Butterfly model of care across its 5 LTC homes.
We strive to apply continuous quality improvement processes in each of the homes. We achieve this by working together to align our efforts to ensure we are caring for our residents consistently across our homes.
While we work towards the same goals, we recognize that the residents in each home may have unique needs and may require different levels of care. As such, a tailored approach in the quality improvement processes for each home may at times be necessary and appropriate.
Region of Peel Long Term Care divisional priorities
We use a variety of information to guide our understanding of the areas in the home that require improvement.
This includes using the Quality Improvement Plan indicators from Ontario Health as well as using satisfaction surveys to better understand the resident, family, and caregiver experience.
Timely and efficient transitions
- Reduce the rate of potentially avoidable emergency department visits for long-term care residents. (Source: Ontario Health Quality Improvement Plan).
- Long-term care homes have responded by implementing a tool that measures early detection of health decline in residents (called the Preview-ED Tool).
Patient, client, and resident experience
- Increase the satisfaction rate among residents who agree with the statement, “[Employee] takes the time to talk and listen to me.” (Source: Resident Experience Survey)
- Increase satisfaction rate among residents who agree with the statement, “I can express my opinion to employees without fear of consequences.” (Source: Resident Experience Survey)
- Long-term care homes have responded with interdisciplinary work primarily led by social work that supports communication with families and residents.
Safe and effective care
- Reduce the number of long-term care home residents (without a diagnosis of psychosis) who are given antipsychotic medication. (Source: Ontario Health Quality Improvement Plan)
- Long-term care homes have responded with interdisciplinary work primarily led by Behaviour Support Ontario Nurses (BSON) to support an Antipsychotic Reduction Program.
Communication with families and residents
- Enhance the resident experience by fostering improved communication between the employee and resident and the employee and the resident’s family. (Sources: Resident Experience Survey, Family Caregiver and Experience Survey)
Menu and dining experience
- Enhance the resident experience by offering a variety of high-quality food options that enhance the overall dining experience. (Source: Resident Experience Survey)
Activities offered to residents
- Create opportunities to engage residents by offering a variety of activities that meet their interests and needs. (Source: Resident Experience Survey)
- Ensure we are meeting the resident’s physical, mental, social, and environmental needs by including them in the planning and decision- making of leisure activities offered in the home. (Sources: Resident Experience Survey)
- Optimize processes to minimize waste and inefficiencies in laundry services that benefit residents. (Source: Resident Experience Survey)
We are flexible and adaptive in our approach to identifying home-specific priority areas.
Areas of improvement in one year might later change in the future as other priorities take precedence in the home.
Top 3 priority areas for Davis Centre
Based on the 2021 Resident Experiences Survey (RES) and Family and Caregiver Experience Survey (FCES) results, these are the top 3 identified areas for improvement that were specific to Davis Centre:
|Priority area||Priority description and actions|
|Quality of life for Residents||There are opportunities to increase residents’ recommendations of the home to others.|
|There are opportunities for improving residents’ experience related to their interactions with their doctors.|
|Communication with families and residents||There are opportunities to improve the way employees communicate with residents.|
The CQI program provides opportunities for LTC employees to identify issues that may result in improvement.
A variety of measures are assessed through annual, quarterly, monthly, and daily reviews to support the identification of priority areas for improvement.
Employees within the homes try out ideas using a variety of Quality Improvement Methodologies including Lean and PDSA cycles.
Lean tools like the “The 5 Whys” are used to determine the root cause of the issues and concerns that are raised.
Once a root cause is determined, Plan, Do, Study, Act (PDSA) cycles are used to try out changes on a small scale. Testing on a smaller scale helps employees determine if ideas work in different settings before rolling the ideas out more broadly in the home.
Current processes used to identify the home’s quality improvement priority areas include:
- Resident Experience Survey (RES) and Family and Caregiver Experience Survey (FCES)
- Review and analysis of complaints and critical incidents
- Review and analysis of performance indicators
- Daily Continuous Improvement Program (CIP)
- Engagement of resident and family councils and resident and family town halls
- Employee town halls
- Educational needs assessment
Resident Experience Survey (RES) and Family and Caregiver Experience Survey (FCES)
The RES and FCES are important data sources used to understand the resident, family, and caregiver experience.
We make every effort to promote completion of these surveys to achieve high response rates. Residents can choose to complete the survey either electronically or by using a paper-based version.
We use volunteers if residents need help to complete the survey. When volunteers aren’t available, families or designates help residents complete the survey.
We outline survey results annually into home-specific and divisional summaries.
We use formal and informal channels every year to review and discuss survey results with employees, residents, families, and caregivers.
The survey results guide the identification of the home’s priority areas for quality improvement. Homes make every reasonable effort to act on survey results to improve how they deliver programs and services.
Review and Analysis of complaints and critical incidents
The leadership team reviews and analyses all documented complaints and critical incidents at least once a month.
We use the data we collect to identify one-time occurrences. We also use this data to pinpoint recurring and system trends to guide quality improvement and risk-management activities.
We address any complaints we receive within 10 business days.
Review and analysis of performance indicators
The leadership team reviews, analyzes, and compares service and program outcomes against set standards and historical performance. This helps us objectively measure the level of service provided.
Performance indicators are recorded monthly, quarterly, and annually as appropriate. We regularly share these indicators with management and front-line employees at team meetings.
We implement corrective actions and process improvements as required.
Davis Centre also demonstrates its commitment to continuously improve service quality and to focus on satisfaction through the Accreditation process.
CARF® International is an independent accrediting body of health and human services.
CARF-accredited service providers have applied CARF’s comprehensive set of standards for quality to their business and service delivery practices.
Davis Centre received a 3-year accreditation in 2019.
Daily Continuous Improvement Program (CIP)
The Daily CIP program was developed by SickKids Hospital.
The program brings a small group of employees into each home area together to discuss challenges they experience in their day-to-day work.
Recommendations take place to improve the work and to identify longer-term opportunities and ‘quick-wins’ that will help make the floor more effective and sustainable.
Engagement of resident and family councils and resident and family town halls
In addition to annual satisfaction surveys, we receive feedback from residents and families through council meetings, town halls, and the resident voice program.
These venues also provide peer-to-peer support and the opportunity to share information, discuss potential program ideas, and stay informed.
Ongoing opportunities to engage residents and their families help support improvements that reflect the collective voice and experiences of those living in the home.
Employee town halls
Employees have several avenues to contribute to the CQI process, including divisional town hall meetings.
The town hall is a forum for employees to have honest and open discussions with leadership to identify issues of concern related to work, processes, and ways to improve efficiencies.
The employee perspective contributes to the development of viable solutions, and employees are empowered to identify CQI opportunities that will improve delivery of care and services.
Educational needs assessment
An annual online survey for employees captures employees’ perspectives in regards to education needs.
Although this is a requirement of Ministry of Long-Term Care legislation, the survey is designed to identify areas of improvement in education to enhance employee knowledge and the transfer of knowledge to practice.
The content of the survey will vary from year-to-year, based on operational needs and current practice. This survey is used to plan employee education for the upcoming year.
The CQI Program uses the Model for Improvement to develop, test, and implement improvements.
This is a structured approach that identifies key areas for improvement across the service delivery continuum.
Davis Centre committees include:
- The Centre Leadership Team (CLT)
- The Continuous Quality Improvement Committee
- The Infection Prevention and Control Committee
- The Falls, Restraints and PASD Committee
- The Pain, Palliative and End of Life Care and Ethics Committee
- The Skin and Wound and Continence Care Committee
- The Responsive Behaviour and Purposeful Engagement Committee
- The Health Services Advisory Committee
- The Joint Occupational Health and Safety Committee
- Restorative and Rehabilitative Care
- The Education Committee
These committees are in place to support the quality of care and services provided to residents.
Committees are interdisciplinary, which supports the identification of important issues from various perspectives.
To support transparency in our work, each committee has a communication board to highlight the progress of relevant improvement initiatives. These boards are intentionally placed in public areas of the home.
In support of continuous quality improvement, each committee:
- Participates in reflective practice.
The home provides treatments and interventions to promote quality of care and services for residents.
- Reviews, tracks, and monitors progress.
All relevant indicators are reviewed to identify important trends.
- Plans, develops, implements, and evaluates.
We evaluate quality improvement initiatives as part of quarterly, annual, and ongoing reviews of the program.
We make efforts to ensure the home provides strategies to maximize residents’ independence, comfort, and dignity. This includes the use of equipment, supplies, devices, and assistive aids as applicable.
We audit and monitor resident care plans to evaluate outcomes and effectiveness. We also develop action plans to meet gaps in services and programs.
We evaluate and update programs annually in accordance with evidence-based practices or prevailing practices.
LTC performance indicators are established in consultation with various stakeholders, the LTC divisional management team, and specific employee peer groups.
The purpose of these indicators is a consistent approach to monitoring service delivery through measurement and evaluation practices.
These indicators give employee peer groups and the whole division the opportunity to monitor, analyze, and track progress. We then set targets for indicators based on past data or industry benchmarks (or both).
The processes we use to study and monitor quality indicators and implement adjustments include:
- An annual review of quality indicators and associated targets.
- An ongoing review of specific data by each department.
- Conducting root cause analyses.
- Action plan development.
- Communication of survey results with residents and families.
- Program evaluation.
This includes the responsible employee peer groups, external stakeholders, and Divisional CQI Committeereviewing the indicator for relevance.
We use data to identify important trends and improvement opportunities.
We then use this information to inform program planning decisions for each department. Significant variances or high-risk trends are brought forward to the Administrator for decision-making.
It’s important that any area or issue identified as needing improvement be evaluated to determine its root cause. We use Root Cause Analysis tools and techniques for this purpose.
Once priority areas for quality improvement are identified, the Quality Management Specialist helps to develop action plans that are shared with the home’s employees.
The home ensures action plans are implemented and sustained. Follow up on any outstanding concerns happens in a timely manner.
We communicate survey results for the Resident Experience Survey (RES) and the Family and Caregiver Experience Survey (FCES) to residents and families, and we receive feedback through the Resident’s Council and Family Council.
We also communicate action plans informed by these surveys to residents and families to gather their feedback and suggestions.
Programs are evaluated annually using relevant evaluation tools and quality improvement methodology.
This includes ensuring that program goals are SMART (specific, measurable, achievable, realistic, and have a start and end date).