Quality Improvement Plan

Baycrest is pleased to share our Quality Improvement Plan (QIP) with our clients, family members and broader community.  The QIP is a requirement under the Excellent Care For All Act, 2010 and was approved by the Baycrest Board of Directors.

This plan describes the key actions we are committed to taking to make improvements to the care and services you receive.  As in previous years, these improvement priorities are rooted in our strategic goal to deliver exceptional quality of care and quality of life for our patients and residents.

Our QIP was developed with extensive feedback from clients, staff and physicians and reflects what they told us matters most to deliver safe, high quality care. Along with a review of our improvement achievements and challenges over the past year, required standards, legislation, and best practices, our QIP reflects consistent themes across our organization while at the same time, making sure these priorities reflect the specific needs of our long term care facility, hospital and ambulatory care programs.

While we continue to work on many other improvement projects, for 2017/18, our main improvement objectives include:

  1. Improving the Client Experience:
    Baycrest’s mission is to provide an exemplary care experience for our clients. Recognizing that every client perceives and experiences care differently, we want to improve how we work in partnership with our clients and their families to truly understand their needs and deliver individualized care that consistently provides the best client experience. Our plan includes activities that, based on client and family input, we believe will contribute to an improved experience. As well, we know how much staff engagement impacts our clients’ experience which is why we continue to monitor our employee engagement levels and have identified activities that we believe will contribute to a highly engaged workforce.
  1. Reducing Harm to Clients:
    We are working to reduce harm across the organization in a number of ways. Falls are a leading cause of preventable injury for our hospital patients and a fall that results in a serious injury can lead to a number of challenges including worsening mobility, decreased quality of life, transfers to the Emergency Department and need for higher level of care. While not all falls are preventable, we are committed to taking steps to make sure our clients are free from injury and harm whenever we can. For residents of our long term care facility, maintaining our residents’ mobility and independence provide a better quality of life and promote health and wellbeing. By providing restorative care, we hope to maintain and improve the independence of our residents for as long as possible. 
  1. Ensuring Effective Transitions:
    By reducing preventable transfers to the Emergency Department we want to improve the safety, efficiency and effectiveness of the healthcare system. Residents living in long-term care homes are being admitted with high functional dependence and increasing levels of complexity: a large number have multiple chronic conditions, need monitoring and are living with Alzheimer’s disease or other dementias. For LTC Home residents, visits to the Emergency Department can cause additional health care risks, breakdowns in care coordination and undue anxiety for them and their families. Preventing our residents from unnecessary visits to the Emergency Department is one of our most important priorities for our residents’ care and safety.
  1. Providing access to the right level of care
    Alternate Level of Care (ALC) refers to patients who no longer need treatment in a hospital, but who continue to occupy hospital beds as they wait to be discharged or transferred to another care environment. Once again, Baycrest has elected to include this as an indicator on the QIP while acknowledging that ALC is truly a cross-sector challenge. In the coming year, our improvement team will continue to work on implementing best practices directed at reduce ALC pressures and help patients access the right level of care they need.
  1. Improving medication safety
    Patients often receive new medications or have changes made to their existing medications at times of transitions in care. At Baycrest, we are building on our experience implementing our inpatient medication reconciliation system and spreading it to ambulatory services. Medication reconciliation refers to the process of avoiding inadvertent inconsistencies across transitions in care by reviewing the patient’s complete medication regimen at the time of admission, transfer, and discharge. By reducing potential discrepancies we reduce the risk for adverse drug events. Another key benefit of medication reconciliation is that it acts as an important communication tool by keeping everybody involved in a patient’s care clear about the medications a patient should or should not be taking.

Our Quality Improvement Plan consists of the following documents:

You can also read our Progress report on our 2016-17 Quality Improvement Plan, which demonstrates the progress we have made on the targets set out in our previous year’s QIP.

The Excellent Care for All Act, 2010 also requires that compensation of the executive team be linked to achievement of some performance targets in the Quality Improvement Plan. The Board of Directors developed and approved the performance-based compensation plan.