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Quality Improvement Plan

Background on the Quality Improvement Plan

In June 2010, the Ontario Government passed the Excellent Care for All Act. This legislation will help support hospitals to further improve the quality and safety of care they provide for members of our community.

One of the ways that the Excellent Care for All Act is helping hospitals meet our community’s expectations regarding quality, patient safety and accountability is through the public reporting of Quality Improvement Plans (QIP).

Quality Improvement Plans provide a meaningful way for LDMH to clearly articulate our accountability to our community, patients and staff. Our QIP is focused on creating a positive patient experience and delivering high quality health care.

Information about Quality Improvement

LDMH is a SAFE hospital that provides a high level of QUALITY care. We know this because we meet many regulatory standards that measure quality and safety.  

Quality improvement is an ongoing priority that helps us continually finds new and better ways of doing things so that we can enhance care for patients, increase satisfaction and achieve even better clinical outcomes.

Every hospital in Ontariois guided by the “Ontario Quality Health Council”. This Council provides direction in the standards of care and new directions in how care should be provided based on evidence based research.

The Ontario government monitors the quality of care in hospital by establishing mandatory reporting of key indicators of quality.
Every year hospitals are required to develop and post the quality improvement initiatives they are working on. This is called the Corporate Quality Improvement plan. Our most recent plan can be viewed below.

Our Quality Improvement Plan, or QIP, is one tool that we are using to help us document and review our current performance in a variety of areas. With this plan, we will be able to very clearly see our targeted areas for improvement and chart our progress.

Quality of care is monitored by the Hospital Board. The government mandates who should sit on the Quality Council of a hospital and what they are responsible to oversee and ensure care meets specific standards.

The medical staff also has a quality of care committee. Each year they work on an improvement project. In 2010/11 the improvement was in preventing clot formation in patients at risk. In 2011/12 the improvement plan is in preventing urinary track infections in patients in hospital.

The patient safety plan is another quality initiative all hospitals are required to develop and monitor. Again key performance indicators are established, monitored and reported. Some of the reporting is public. An example of this is the hand washing rate and the number of infections caused by superbugs that were acquired while the patient was in hospital.

In addition to the Ontario Health Quality Council all hospitals undergo an external review process called Accreditation, every 3 years. This is carried out by the Canadian Council of Healthcare Accreditation. LDMH is a fully accredited hospital.

Our Quality Improvement Plan (QIP) is made up of two parts:

1. A document that provides a brief overview of our quality improvement plan, highlighting and listing our hospital’s top priorities for the year.

2. A spreadsheet that includes our improvement targets and initiatives. The spreadsheet includes a core set of indicators that all similar hospitals across the province are working on.

The Ontario Health Quality Council has requested that all hospitals report on a series of core indicators to support province-wide comparisons. The core indicators that apply to our hospital are reflected in our QIP.

The QIP is only one of the ways we are working to improve our patients’ experiences. Please feel free to contact us with any questions you may have.

Click here to view the (QIP) Schedule A for 2016-2017
Click here to view the (QIP) Schedule B for 2016-2017

Click here to view the (QIP) Schedule A for 2015-2016
Click here to view the (QIP) Schedule B for 2015-2016
Click here to view the 2015-2016 QIP Progress Report

Click here to view the (QIP) Schedule A for 2014-2015
Click here to view the (QIP) Schedule B for 2014-2015
Click here to view the 2014-2015 QIP Progress Report

Click here to view the (QIP) Schedule A for 2013-2014
Click here to view the (QIP) Schedule B for 2013-2014
Click here to view the 2013-2014 QIP Progress Report

Click here to view the (QIP) Schedule A and B for 2012-2013
Click here to view the 2012-2013 QIP Progress Report

Click here to view the (QIP) Schedule A for 2011-2012
Click here to view the (QIP) Schedule B for 2011-2012
Click here to view the 2011-2012 QIP Progress Report

How is the QIP developed?

The Board of Directors for LDMH and our Quality Council are responsible for overseeing the development of the Quality Improvement Plan. The members of our Board and the Quality Council work closely with our community and with our team of health care professionals to determine areas where we are doing well and areas where we have room for improvement. From there, we set targets for the organization, which are reflected in the plan.

Can the QIP be used to help patients choose a hospital?

Patient safety and high quality care is a longstanding priority for our hospital. The Quality Improvement Plan does not change that. The plan is one way that we are keeping our focus on constantly doing better. You may want to talk to a member of your health care team about how we are doing in a specific area, but know that we strive to provide every patient with the best possible care.

What timeframe does the QIP cover?

Quality Improvement Plans are completed, submitted to the Ontario Health Quality Council and posted publicly annually at the start of each fiscal year, April 1st.

The Link to Performance-based Compensation of Our Executives

LDMH's Executives' Compensation will be directly linked to the 2011-2012 QIP in adherence with Ontario's Regulation 444/10.

All of LDMH's Executive Team will have a portion of their salary direcly linked to achieving the goals set for the corporate objectives under 2013-2014 QIP.

The Executive Team consists of:

  • the CEO
  • members of Senior Management who report directly to the CEO, and
  • the Chief of Staff

Click here to view the Performance Based Compenstion (PBC) Plan

Click here to view the PBC Improvement Targets & Initiatives

Where can I find out more information about the Excellent Care for All Act and quality improvement plans?

Please visit http://www.health.gov.on.ca/en/ms/ecfa/public/default.aspx for more information about the legislation and its requirements, including the Quality Improvement Plan.

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