Osler's 2015/16 Quality Improvement Plan Progress Report

Our Quality Improvement Plan (QIP), plays a part in demonstrating specific things we are focusing on as an organization over the next year to improve the care we provide to our community. To promote accountability, the compensation of Osler's executives is tied to the achievement of the improvement targets outlined in the QIP.

The QIP consists of 4 parts:

  • PART A: Overview of our hospital's Quality Improvement Plan 
  • PART B: Our improvement targets and initiatives 
  • PART C: The link to performance-based compensation of our executives 
  • 2015-16 QIP Accountability Signoff

Click here to download Osler's 2015-16 QIP



Starting Performance

 Are We On Track?

Reduce hospital acquired infection rates
Clostridium difficile infection (CDI) rate per 1000 patient days (number of patients newly diagnosed with hospital-acquired CDI)

0.30 or lower
(as per provincial annual average set by the ministry)



Increase proportion of patients receiving medication reconciliation upon admission Percentage of Best Possible Medication History (BPMH) completed on admitted patients through the emergency department

(10% increase over year end)


All change plans were implemented. This was the first year of a multi-QIP plan that has seen gradual improvement on this metric.



Starting Performance

 Are We On Track?

Improve organizational financial health
Total margin: Percentage by which revenues exceed expenses



Ministry of Health revenues do not match growing hospital costs. The hospital completed an annual planning cycle In addition, there are different projects undertaken each year to find new efficiencies.



Starting Performance
 Are We on Track?

Reduce wait times in the ED
90th percentile Emergency Department (ED) length of stay for admitted patients

33.3 hours
(5% improvement over year end)

36.1 hours

The relative proportion of high acuity patients is the highest in the province.  The winter of 14-15 saw the worst influenza season in 5 years nationally which crippled EDs across the province including at Osler.



Starting Performance
 Are We on track?

Improve patient satisfaction
From internal surveys: In-house Emergency Department patient satisfaction survey: provide the % response to a summary question such as the "Willingness of patients to recommend the hospital to friends or family"

(5% over current performance)


 This year we changed our QIP focus from in patient satisfaction to ED patient satisfaction, one of the most challenging populations. Some of the change plans were implemented and others remain in progress.



Starting Performance
Are We on Track? 

Reduce unnecessary time spent in acute care
Percentage of total patient days that are designated as Alternate Level of Care (ALC) days

(As per HSAA)



Reduce unnecessary hospital readmission
Percentage of patients readmitted within 30 days to any facility for select Case Mix Groups (CMG's)




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