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Quality strategic plan
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Quality culture

The quality culture element focuses on creating an enabling environment to support quality through empowered quality leaders, healthy staff, effective teams and supporting structures.

Quality ElementWhat it means for staff

What it means for patients

Culture

I am quality at Sunnybrook.

Sunnybrook provides excellent care.

 Lead in Developing a Quality Culture With Empowered Leaders, Healthy Staff, High Functioning Teams and Supporting Structures
ObjectiveActions
Strengthen efforts to develop leaders in quality care

Implement the iLead Quality and Patient Safety Program Plan to build leadership capacity.
Increase collaborations with the Centre for Quality Improvement and Patient Safety (CQuIPS) to leverage their clinical leadership development expertise, and better align Sunnybrook’s and CQuIPS’ quality goals and interests.
Align the priorities of the Alternate Funding Plan (AFP) Innovation Fund Program and the Practice-based Research and Innovation Fellowships and Seed Grants with advancing the Quality Plan’s goals and objectives.
Support staff to provide the best care and celebrate their quality achievements Provide opportunities to staff to grow as providers of compassionate quality care.
Expand quality of work life initiatives and celebrate staff contributions to advancing quality.
Increase the use of best practices for effective teams Implement the Interprofessional Collaboration Strategy to strengthen interprofessional teams and culture.
Improve effective interprofessional team collaboration using simulation training.
Apply a comprehensive and structured business intelligence approach to accelerate data-informed quality improvements Leverage Sunnybrook’s information system priorities to support a comprehensive structured approach to achieving quality goals that integrates clinical, academic and operational data.
Engage medical leadership to champion quality performance.

View the implementation plan »

 Strengthen efforts to develop leaders in quality care
ActionsSpecific deliverables and timelines
2016/17 2017/18 2018/19

Implement the iLead Quality and Patient Safety Program Plan to build leadership capacity.

 


  • Implement the Program Plan’s Year 1 goals and deliverables.
  • Implement the Plan’s Year 2 goals and deliverables, and meet Year 2 evaluation expectations.
  • Complete implementing all the Plan’s goals and deliverables.
  • Develop an evaluation plan with performance measurements, and meet Year 1 evaluation expectations.
  • Meet Year 2 evaluation expectations.
  • Evaluate the impact of the Plan.
  • Host a summit to showcase the achievements and impact of iLead.

Increase collaborations with the Centre for Quality Improvement and Patient Safety (CQuIPS) to leverage their clinical leadership development expertise, and better align Sunnybrook’s and CQuIPS’ quality goals and interests.

  • Identify opportunities for iLead faculty to collaborate with CQUIPS to develop physician-specific leadership training programs based on CANMEDS (A framework developed by the Royal College of Physicians and Surgeons of Canada that identifies and describes the abilities physicians require to effectively meet the health care needs of the people they serve) competencies
  • Implement at least one new training opportunity.
  • Implement at least one new training opportunity.
  • Implement at least one new training opportunity.
  • Collaborate to develop and implement city-wide quality and patient safety education rounds.
  • Continue to implement city-wide rounds.
  • Continue to implement city-wide rounds.
  • Identify project-specific collaborations, prioritize opportunities and implement the top priority(ies).
  • Continue to implement priority project-specific collaborations.
  • Collaborate to develop and mentor quality academic roles at Sunnybrook for non-physicians.
  • Continue to collaborate on quality academic roles for non-physicians.
Align the priorities of the Alternate Funding Plan (AFP) Innovation Fund Program and the Practice-based Research and Innovation Fellowships and Seed Grants with advancing the Quality Plan’s goals and objectives.
  • Collaborate with AFP Innovation Fund Program leads to develop guidelines and/or grant review criteria to support better alignment with Sunnybrook’s quality goals and objectives, and use to guide funding.
  • Continue to use the revised guidelines and/or grant review criteria for funding decisions.
  • Continue to use the revised guidelines and/or grant review criteria for funding decisions.
  • Align Toronto Academic Health Science Network (TAHSN) Fellowships and Seed Grant proposal eligibility criteria with Sunnybrook’s strategic quality goals and objectives.
  • Continue alignment.
  • Continue alignment.
  • Create a Quality and Patient Safety-funded TAHSNp Fellowship.
  • Continue the Quality and Patient Safety-funded TAHSN Practice Committee (TAHSNp) Fellowship, and determine the feasibility of expanding with sustainable funding.
  • Continue the Quality and Patient Safety-funded TAHSNp Fellowship.
Support staff to provide the best care and celebrate their quality achievements
ActionsSpecific deliverables and timelines
2016/17 2017/18 2018/19
Provide opportunities to staff to grow as providers of compassionate quality care.
  •  Implement bimonthly (every two months) Schwartz Center Rounds that rotate to Sunnybrook’s three campuses and are open to all hospital and medical staff, learners and volunteers.
  • Continue to implement bimonthly Schwartz Center Rounds.
  • Evaluate the impact of the rounds and make adjustments, as required.
  • Continue to implement bimonthly Schwartz Center Rounds.
  • Evaluate the impact of the rounds and make adjustments, as required.
Expand quality of work life initiatives and celebrate staff contributions to advancing quality.
  • Identify and provide at least one new program for health resilience and wellness for staff as part of the Quality of Work Life Program.
  • Increase staff participation by 5-10% in the health resilience program(s) for staff.
  • Increase staff participation by an additional 15% in the health resilience program(s) for staff.
  • Identify and develop – as part of the Quality of Work Life Program – at least one new initiative that recognizes and celebrates staff for their contributions to quality and compassion in daily care, performance improvement, and academic practice (e.g., Compassion Award).
  • Implement the annual quality and compassion recognition and celebration initiative(s) and promote staff and leadership support and participation.
  • Implement the annual quality and compassion recognition and celebration initiative(s) and promote staff and leadership support and participation.
Increase the use of best practices for effective teams
ActionsSpecific deliverables and timelines
2016/17 2017/18 2018/19

Implement the Interprofessional Collaboration Strategy to strengthen interprofessional teams and culture.


 

  • Integrate Interprofessional Core Competencies in unit- based teams (including medical and hospital staff, learners, volunteers) across all programs and campuses.
  • Integrate Interprofessional Practice (IP) Core Competencies in unit-based team processes (e.g., huddles, care planning rounds) across all programs and campuses.
  • Sustain IP Core Competencies through performance evaluation and feedback.
  • Pilot a Team Assessment Process with six teams (across clinical settings and campuses) using self-assessment tools, shared learning and the development of Team Success Plans.
  • Develop an evaluation process for effective team collaboration and patient experience.
  • Refine the Team Assessment Process based on the pilot.
  • Implement the Team Assessment Process in all unit-based teams across all programs and campuses.
  • Evaluate the impact of the Team Assessment process and associated Team Success Plans on effective team collaboration and patient experience.

Improve effective interprofessional team collaboration using simulation training.

  • Establish a working group to identify effective team development programs that use simulation, incorporate Interprofessional Core Competencies, and can be targeted at the program level.
  • Prioritize scalable and innovative program(s) to implement and the program(s) of focus.
  • Develop an implementation plan (including resource requirements and an evaluation approach).
  • Implement the selected program(s) in the program(s) of focus, and evaluate.
  • Complete implementing the selected program(s) and evaluate impact.
 Apply a comprehensive and structured business intelligence approach to accelerate data-informed quality improvements
ActionsSpecific deliverables and timelines
2016/17 2017/18 2018/19

Leverage Sunnybrook’s information system priorities to support a comprehensive structured approach to achieving quality goals that integrates clinical, academic and operational data.

 

Continue to expand Information Management (IM) tools that integrate and use clinical, academic and operational data:

  • Top-level organizational patient safety and quality risks through the Enterprise Risk Management Program.
  • iLead Data Portal to monitor and identify quality issues at the local/unit levels and provide individual-level information.
  • Program Dashboards (e.g., validate current indicators, add QIP indicators, etc.) to track and address quality issues at the senior program leadership levels.
  • Data visualization, analytical and functional tools designed to support and inform clinical users to identify and address quality of care including next generation health informatics and analytics tools through SunnyCare and MyChart.
  • Implement IM tools that enhance the integration and use of comprehensive data to support greater population health management and health informatics analytics at Sunnybrook.
  • Develop partnerships to support the continued expansion of information management tools that enhance the integration and use of comprehensive data to support greater population health management and health informatics analytics system wide.

Engage medical leadership to champion quality performance.

  • Develop a Medical Advisory Committee (MAC) policy requiring all Departments / Divisions to hold morbidity & mortality (M&M) reviews (include minimum expectations).
  • Develop a template and reporting schedule for presentations by Chiefs to the MAC, demonstrating compliance, activate the schedule and begin presentations.
  • Integrate Morbidity & Mortality (M&M) performance management with initiatives in system reviews and independent practice reviews.