Quality Improvement Plan

Measure
Measure/IndicatorTypeUnit / PopulationSource / PeriodOrganization IdCurrent performanceTargetTarget justificationExternal Collaborators
Number of ED visits for modified list of ambulatory care–sensitive conditions* per 100 long-term care residents.PRate per 100 residents / LTC home residentsCIHI CCRS, CIHI NACRS / Oct 2021 - Sep 202254434*10.497.86To decrease our current performance percentage by 25% to meet our target performance.
Percentage of residents responding positively to: "What number would you use to rate how well the staff listen to you?"P% / LTC home residentsIn house data, NHCAHPS survey / Apr 2022 - Mar 202354434*97.399.00Although we would like to maintain our current target, we would prefer to achieve a better target by 1.75%.
Percentage of residents who responded positively to the statement: "I can express my opinion without fear of consequences".P% / LTC home residentsIn house data, interRAI survey / Apr 2022 - Mar 202354434*100100.00To maintain our current target.
Percentage of LTC residents without psychosis who were given antipsychotic medication in the 7 days preceding their resident assessmentP% / LTC home residentsCIHI CCRS / Jul - Sept 202254434*28.4321.10To decrease our current performance percentage by 25% to meet our target performance.