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Continuous quality improvement at Tall Pines

Tall Pines is committed to ongoing and continuous quality improvement.

Report objective

This Continuous Quality Improvement Report is for the 2023-2024 fiscal year. It meets the requirements set out in Section 168 (6(5, 6)) of the O. Reg. 246/22 of the Fixing Long Term Care Act, 2021. Included in this report is information on the Quality Improvement Plan (QIP) program cycle for 2023 to 2024.

This report was completed on March 31, 2023.

Other information

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.

Tall Pines 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: Jessica Altenor

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, Peel Region has been working to implement the Butterfly model of care across its 5 long term care 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.

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 Health Quality Ontario as well as using satisfaction surveys to better understand the resident, family, and caregiver experience.

During the past year, quality improvement activities centered on the following divisional priority areas:

Timely and efficient transitions: Reduce the rate of potentially avoidable emergency department visits for long-term residents. Tall Pines has responded by implementing the Preview-ED tool - a tool that measures early detection of health decline in residents.

Patient, client, and resident experience: Activities carried out in the past year focused on increasing satisfaction rates among residents who agree with the statement: "Staff take the time to talk and listen to me" and "I can express my opinion to employees without fear of consequences". Tall Pines has responded with interdisciplinary work that supports fostering communication with families and residents.

Safe and effective care: Reduce the number of long-term care residents (without a diagnosis of psychosis) who are given antipsychotic medication. Tall Pines has responded with interdisciplinary work primarily led by Behaviour Support Ontario Nurses (BSON) to support an Antipsychotic Reduction Program.

Menu and dining experience: Enhance the overall dining experience by offering a variety of high-quality food options. Tall Pines has supported this priority by engaging in collaborative discussions with residents about potential improvements to the menu and food offered at the home.

Activities offered to residents: Create opportunities to engage residents by offering a variety of activities that meet their interests and needs. Tall Pines has responded by including residents in the planning and decision-making of leisure activities offered in the home.

Home-specific priority areas

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. The priority indicators and change ideas for the 2023-2024 year are outlined in our continuous quality improvement workplan.

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
  • Accreditation
  • 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.


Tall Pines 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.

Tall Pines 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.

Tall Pines 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.
  • 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.

  • Reviews, tracks, and monitors progress.
    All relevant indicators are reviewed to identify important trends.
  • We audit and monitor resident care plans to evaluate outcomes and effectiveness. We also develop action plans to meet gaps in services and programs.

  • Plans, develops, implements, and evaluates.
    We evaluate quality improvement initiatives as part of quarterly, annual, and ongoing reviews of the program.
  • 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.
  • This includes the responsible employee peer groups, external stakeholders, and Divisional CQI Committeereviewing the indicator for relevance.

  • An ongoing review of specific data by each department.
  • 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.

  • Conducting root cause analyses.
  • 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.

  • Action plan development.
  • 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.

  • Communication of survey results with residents and families.
  • 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.

  • Program evaluation.
  • 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).

The Resident Experience Survey and Family and Caregiver Experience Survey are important data sources used to understand the resident, family, and caregiver experience. We use formal and informal channels to review and discuss survey results every year 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 programs and services are delivered.

The Resident Experience survey was administered on August 11, 2022, and the Family Experience Survey was administered on October 11, 2022. Both surveys were analyzed, and results presented in a data dashboard made available to all staff on December 19, 2022. The survey results helped to inform many of the initiatives highlighted in this report and associated Quality Improvement Work Plans including (but not limited to) the “point-in-time” meal service feedback app and the Resident Voice Program. Results of both surveys were also shared with our Resident Council on January 18, 2023, and Family Councils on March 21, 2023. During these sessions, collaborative dialogue took place and additional change ideas were discussed with staff. Survey results for were also posted on a communication board at the home on March 30, 2023.

In addition to sharing survey results with residents, families, and councils, we will also share the Quality Improvement Plan (QIP) for the upcoming year with our councils. In this way, we invite accountability and transparency to our CQI work. Our Quality Improvement Plans will be driven, monitored, and evaluated by our Quality Improvement Committee which now also includes both a resident and a family representative.

The Quality Improvement Plan is an organization-owned document that sets to establish the home's plan for quality improvement over the coming year. This includes documenting the set of quality commitments we make to our residents, families, and staff related to quality-of-care issues identified at the home.

Access the Quality Improvement Plan for Tall Pines.