The Canadian Institute for Health Information provides LaPointe-Fisher with quarterly indicators that are specific to the long term care sector and allow us to benchmark and monitor our performance against other homes, as well as the province. These indicators, as well as Ministry of LTC inspection reports, internal monitoring records and our resident/family surveys, are what we use to help us identify our priority areas.
We are currently in the process of establishing a quality improvement committee which will be led by Dahlia Burt-Gerrans, our Administrator and composed of a member of our Resident Council, a member of our Family Council (if applicable), our Director of Care/Nursing, our Medical Director, each Designated Lead of our Home, our Registered Dietitian, our Consulting Pharmacist, a regular Nursing Staff of the home, and a PSW of the home. As we complete the action items identified in our quality report, status updates will be provided on a quarterly basis to the Quality Improvement Committee. Final outcomes will be detailed in the quality report at the end of each fiscal year.
Our priority areas for the current fiscal year include:
- Unnecessary visits to the emergency department – This is a priority area that has been identified in our community and we are working with our healthcare partners to achieve this. Our goal is to improve our performance, which has been significantly above the provincial average, by the end of the fiscal year. Most of these visits are due to falls with injury or pneumonia.
- Unnecessary Antipsychotic Use – This is a priority area where our home is above the provincial average. In addition to medication reviews and audits, this can be reduced by improving our Behaviour Management Program which is addressed through a separate priority area below
- Patient-Centered Care – We have a question on our resident/family satisfaction survey which asks residents how much they agree with the statement: “I can express my opinion without fear of consequences”. A positive response was received by 77% of residents in our 2021 survey and we are looking to increase this number to 100%.
- Behaviour Management – Our Behaviour Management Program is undergoing a number of improvements this year and we are targeting an increase in hours for our behavioural support staff. We are also planning to increase usage of the best practice “Clinical Support Tools” assessments. The outcome of this will be measured using both complaint submissions regarding other resident behaviours as well as the mean ABS score of our facility. We are hopeful this will also decrease our antipsychotic usage.
- Hand Hygeine – The COVID pandemic has drawn a lot of attention to our infection control program. The greatest factor for preventing disease spread is hand hygiene and it’s an area we have struggled with recently. We are looking to improve our compliance measured by our internal audits.
- Abuse – When there is an incident of abuse involving a resident, a report is filed with the Ministry of Long Term Care which details follow up actions, investigations, and preventative measures for the future. We are looking to reduce our number of these mandatory reports compared to the prior year mainly through continuous education with staff and residents as well as improvements in our Behaviour Management Program. These mandatory ministry reports may involve staff to resident, resident to resident, or visitor to resident incidents.