Continuous Quality Improvement

Mississauga Long Term Care recognizes that quality in care requires efforts from all who serve our resident population and we are committed to continuous quality improvement (CQI). In an effort to continue to provide the best quality of care for our residents, MLTC has identified 4 priority areas to focus on for the fiscal year 2022/2023.

The priority areas identified are: infection prevention (decrease in urinary tract infections (UTI)), skin and wound (prevention of ulcers deteriorating to the next stage), falls prevention (decrease in falls), and pain management (identifying and treating pain). Aside from the aforementioned priority areas, MLTC continues to work towards strengthening other quality indicators within all departments, which include nursing and personal care, housekeeping and laundry, quality of food and the dining experience and all other aspects that contribute to quality care.

We have expanded our continuous quality improvement committee to identify areas for improvement, develop policies, procedures and processes to improve, monitor and measure progress and analyze and communicate outcomes. The CQI team is made up of the leadership members and led by Irene Iftymi, Acting Administrator and Nadine Leslie, RAI-MDS Coordinator/Activation Lead. The CQI committee meets on a regular basis. Ongoing communication exists between the CQI committee, frontline workers, and all other members of the team, as quality improvement is a team effort.

1. Infection Prevention
            Reduction in UTIs.

AIM:  We will improve the prevention of UTI for our residents.

Policies: Infection Prevention and Control Program Policy

Procedures, Processes and Measures:

1. Education of all staff on specific signs and symptoms of UTI and when to collect a specimen (“reflect before you collect.”)
2. Communication with the physician or nurse practitioner.
3. Audit line lists to ensure appropriate documentation.
4. IPAC committee to continue to discuss UTIs at monthly meetings.
5. Interdisciplinary approach to prevent infections.
6. Enhance toileting schedule/check and change, as appropriate.
7. High-risk rounds.
8. Continue to educate on proper peri-care.

Measures:

1. Analysis of fluid intake for high risk residents
2. Analysis of incontinence rates
3. % of staff attending education sessions

2. Skin and Wound
            Preventing stage one ulcer from deteriorating to stage 2.

AIM: We will prevent stage one ulcers from developing into stage 2 ulcers.

Policies: Skin Care and Wound Education, Skin Care and Wound Management Protocol, Skin and Wound Care Program

Procedures, Processes and Measures:

In addition to current interventions and protocols

1. Monitoring (Prevention and Mitigation)
2. Implement scheduled meetings/rounds to discuss high risk individuals
3. Enhance Braden Assessment Schedule.
4. Using a dot system (high risk-red dot, green dot at risk)
5. Hydration risk assessment at appropriate intervals.
6. Program Evaluation
7. Tracking indicators monthly, analyzing trends and reporting to the CQI committee
8. Skin Audits conducted quarterly
9. Education
10. New staff will receive skin and wound education during orientation
11. Staff education sessions continue to be provided annually through Surge Learning.

3. Falls Prevention

            Reduction in falls.

AIM: We will reduce falls.

Policies: Falls Management Program

Procedures, Processes and Measures:

1. Falls risk assessments at appropriate intervals.
2. Education on 4Ps for falls prevention.
3. Intentional hourly rounding for high-risk residents.
4. Individualized interventions.
5. Post fall huddles to be done in an interdisciplinary approach.
6. Interdisciplinary approach to falls prevention.
7. Encourage more participation in falls committee meetings.
8. Weekly floor rounds by falls program lead.

Measures:

1. % of fall risk assessments completed within 72 hours of admission.
2. % of post fall huddles done with the interdisciplinary team.
3. % of staff attending educational sessions

4. Pain

            Timely identification of potential pain in residents

Policy: Pain Management Program

Procedures, Processes and Measures:

1. Analyze current pain management practices
2. Pain assessments at appropriate intervals.
3. Continue monthly pain rounds with pain consultant
4. Implement tool for PSWs to screen for pain
5. Collaboration with resident’s physician.
6. Education that is staff-specific (PSWs, RN)
7. Relevant information gathering upon admission.
8. Weekly pain rounds.

Measures:

1. % of staff who were attending education sessions
2. % of pain assessments done each month
3. % of residents prescribed scheduled analgesics each quarter
4. % of residents receiving prn analgesia each quarter
5. % of residents with potentially painful diagnoses.

Processes and Measures:

Processes used to monitor and measure progress include analysis of RAI-MDS QI data, analysis of data collection on MedeCare, fluid and nutritional intake, incontinence rates, number of staff who attended/completed education, and collection and analysis of quantity and quality of all applicable assessments. The CQI team will meet, at a minimum, of on a monthly basis. Each respective department’s lead will bring forward their analysis of the data for discussion and identification and adjustment requirements. The outcomes will be communicated by placing relevant information on a CQI bulletin board.