The Rekai Centres

Quality Improvement Narrative

Sherbourne Place (SP 2015-16 vs. Ontario 2014-15)

Sherbourne Quality Improvment Graph

Sherbourne Place (SP)
Improved Quality Indicators: “The Green”-70% of all the indicators

  • Falls
  • Worsening Pressure Ulcer
  • Daily physical restraints
  • Pain
  • Worsened pain
  • Worsened or remained dependent in mid-loss ADL
  • Taken antipsychotics without a diagnosis of psychosis

Action plans for these indicators are ongoing to ensure that these remarkable results are maintained. Interdisciplinary care meetings, educations sessions, availability of appropriate equipment (e.g., pressure relieving devices, bed and chair alarms), and audits are some of the interventions that are integrated within the day to day resident care.

Stable Quality Indicators: “The Yellow”-20% of all indicators
These indicators are marginally worse than the Ontario average

Worsened or remained dependent in mid-loss ADL- SP 35.80%; Ontario 35.20%

  • This is the percentage of residents whose status declined on mid-loss ADL functioning (transfer and locomotion) or who continually needs assistance in transferring and locomotion since the last quarter.
  • The current rate (35.80%) shows a slight deterioration from last quarter’s (34.20%) data. This change mirrors the decline in transferring and locomotion abilities of some residents.
  • Data relating to mid-loss ADLs are discussed in meetings attended by QI Lead, RAI-MDS Coordinator, and Physiotherapist to ensure accurate documentation of residents’ abilities in transferring and locomotion.

Worsened mood from symptoms of depression- SP 25.80%; Ontario 25.70%

  • This indicator reflects the deterioration of mood due to symptoms of depression within the chosen quarter.
  • Observation and documentation about mood symptoms are part of the Charge Nurses’ and Personal Support Worker’s (PSW) daily tasks. The Director of Resident Care (DRC) is informed about changes in mood conditions by conducting a daily review of online documentation system and by visiting every unit. Other available supports come from SMH Psychogeriatric Outreach Team and Psychogeriatric Resource Consultant (PRC).
  • Current rate (25.8%) shows an improvement in comparison to previous quarter (29%).  Significantly, trend from Q1 to Q4 2015-16 shows a steady improvement to where it is now. This positive change could be attributed to education sessions (September to October 2015), which targeted documentation discrepancies.

Worsened Indicators: The Red”- 10% of all the indicators:
These indicators are considered to be significantly worse than the Ontario average.

Improved or remained independent in mid-loss ADL- SP 9.20%; Ontario 30.50%

  • This is the percentage of residents whose status improved on mid-loss ADL functioning (transfer and locomotion) or remained completely independent in mid-loss ADLS since the last quarter.
  • Aside from decline in transferring and locomotion abilities due to medical condition, it also influenced by residents’ readiness to participate in strengthening or maintenance exercises.
  • SP has a team of restorative aides, a physiotherapist, and a physiotherapist aide. All of them help improve/maintain residents’ abilities in transfers and locomotion through planned exercises.
  • Data relating to mid-loss ADLs are discussed in meetings attended by QI Lead, RAI-MDS Coordinator, and Physiotherapist to ensure accurate documentation of residents’ abilities in transferring and locomotion.

 

   

 

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