Quality and Risk

Quality and Risk Management

Working in collaboration with internal and external stakeholders, organizational leadership, the Board of Directors and physician leadership, the QRM Department is responsible for the organization wide quality improvement and risk mitigation process, which ensures the integration of management and delivery of safe, quality care.

The main objectives of the QRM portfolio can be categorized into three main areas of responsibility that have cross-organizational implications and impact both operations and practice:

  • Anticipating and perceiving risk.

  • Managing actual risk (such as sentinel events, legal claims and a range of other incidents).

  • Focus on continuous quality improvement to meet the needs of resident care, client and family focused care philosophy, meet current and evolving standards of practice and engage in quality improvement plans.

 

QRM is responsible for identifying, establishing, monitoring and evaluating relevant and appropriate quality indicators and outcome scales that demonstrate organizational responsibility, accountability and commitment to the delivery of safe quality care in compliance with the organization’s established strategic priorities.

The department is also responsible for leading the organization through the licensing and accreditation process. It takes direction and recommendations from Accreditation Canada in terms of the requirements for achieving the delivery of quality care, focusing on improving quality while decreasing risk, both to the organization in the way of resource management and utilization, and to residents through the application of care delivery.

Main focus of the QRM Department:

  • Ensure the organization is in compliance with licensing requirements and implement the corrective actions based on recommendations provided by the licensing officer.

  • Lead the accreditation process and ensure organization maintains its accreditation status.

  • Responsible for the function and success of various organizational committees.

  • Review and update the Integrated Quality Management Framework.

  • Work with each department to establish their quality indicators. Monitor, report and evaluate the organization’s quality indicators and outcome scales.

  • Identify and mitigate real and perceived risk elements to the organization.

  • Establish and lead quality improvement plans based on industry standards and practice requirements.

  • Liaise, consult and advocate with internal and external stakeholders to implement quality improvement activities and resources.

  • Lead the organization in achieving recognition as a centre of excellence.

Frameworks

  • Quality and Risk

  • Ethical Decision Making Framework

  • Person-Centred Care Framework

  • Safety Framework

  • Talent Management Framework

  • Communications and Public Relations Framework

A Risk Registry is a tool that is used to identify potential risks in an organization. It includes all information about each identified risk, nature of that risk, level of risk, who owns it and the mitigation measures in place to respond to it. As risks are identified, they are logged on the register and actions to respond to the risk are taken. The QRM Team supports each department in monitoring and mitigating identified risks by managing our risk registry tool.

 

What is the purpose of having a Risk Registry:

• Minimize the likelihood of harm to our residents and families.

• Enhance the quality of life and resident outcomes.

• Manage our resources efficiently.

• Support legislative compliance.

• Anticipate potential problems ahead of time with pre-emptive actions.

 

How do we identify risks?

• Discussions with Departments Directors, Managers and staff.

• Resident tracer activity (tracing a journey of a patient from admission to discharge).

• Retrospective screening of resident records.

• Regular tracking of Quality Indicators.

• Incident reporting system and emergency events.

• Healthcare associated infection reporting.

• Facility management and safety committee reporting.

• Conduct resident complaints and satisfaction surveys.

• Regular committee reporting.

Risk Registry

  • These are risks that affect the entire organization and its long-term objectives (for example, insufficient resources obtained, inadequate emergency planning or inadequate compliance with regulations).

  • These are risks that affect the functions or services of the organization (for example, human error, flawed processes, broken systems or disruptive external events).

  • These are risks that may affect the success of a project (for example, scope, cost, time management, quality and performance or lack of stakeholder engagement).

Balanced Scorecard and Quality Indicators

What is a Balanced Scorecard?

The Balanced Scorecard is a tool used to measure an organization’s activities and initiatives against its Mission, Vision and Values, as outlined in its Strategic Plan. The tool is designed to help ensure the organization’s activities and initiatives being monitored are comprehensive and reflect a well-balanced approach to achieving the Vision.

This framework is based on the premise that “what gets measured, gets managed.” However, since it is not possible to measure everything, choosing the best quality indicators is critical.

 

What are Quality Indicators?

Quality Indicators are developed for each area of the balanced scorecard and must be selected carefully to ensure they provide a useful measure of the progress the organization is making towards fulfilling its strategic plan.

The acronym “SMART” is used when describing the important considerations in the identification of meaningful indicators. “SMART” reminds us that the indicators we choose need to be specific, measurable, achievable, realistic and timely.

Infection, Prevention and Control

Infection Prevention and Control (IPAC) develops, implements and provides ongoing management of the IPAC programs to prevent the development of new infections and the spread of existing ones, as well as minimize the risk of healthcare-associated infections in residents, families, staff and visitors. IPAC also develops and maintains a surveillance system for the timely collection, tabulation analysis and reporting of communicable diseases.

The team develops, evaluates and updates policies and procedures regarding IPAC based on applicable regulations, organizational priorities, evidence and best practices for continual improvement. It is also involved in the orientation of staff, residents, families, companions, volunteers and visitors.

There is an IPAC Committee, which actively participates in addressing Occupational Health and Safety issues related to IPAC, including:

  • Ensuring the provision of resources needed to support IPAC activities based on the size of the organization and the type services of it provides.

  • Ensuring the provision of Influenza vaccine to staff, companions, volunteers and residents, as well as the Pneumococcal vaccine to residents.

  • Maintaining records of immunization.

The IPAC Team provides input during the planning and designing of the physical environment, including plans for construction and renovation, based on national standards. There is a fulltime Infection Control Practitioner who acts as a liaison between Louis Brier Home & Hospital and Vancouver Coastal Health and the BC Centre for Disease Control during disease outbreaks and pandemics. They communicate and ensure adherence to control measures as recommended by the Medical Health Officer. The Infection Control Practitioner is also accountable for quality oversight and coordinating reprocessing of medical devices and equipment in the facility.

 

COVID-19

The IPAC Team played an integral role in the efforts to manage the impact of the Covid-19 pandemic. They established, implemented and enhanced protocols and practices in alignment with the Ministry of Health, Vancouver Coastal Health Licensing, VCH-PHC Emergency Operation Centre and Medical Health Officers.

In collaboration with our internal Stores Department, local vendors, PHSA, SafeCareBC and donors, the IPAC Team was successful in proactively securing PPEs and establishing a pandemic stockpile as early as January 2020.

The IPAC Team also collaborated with the Interdisciplinary Team in facilitating staff education around IPAC guidelines, including donning and doffing of PPEs, pandemic planning, as well as increased levels of monitoring and surveillance to ensure relevant standards were met.