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Continuing Care Quality Committee
Annual Report to QSEC June 2015 - June 2016
CCQ Annual Report for QSEC June 2016 Page 1 of 20
Continuing Care Quality Committee
Annual Report June 2015 – June 2016
Including 2015/16 Q2, Q3, Q4 updates as per CCQ Terms of
Reference
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Continuing Care Quality Committee
Annual Report to QSEC June 2015 - June 2016
CCQ Annual Report for QSEC June 2016 Page 2 of 20
Introduction
The Continuing Care Quality Committee (CCQ) is on target to
achieve the Continuing Care Quality Management Framework (CCQMF)
vision of “Individual’s and their families will access and receive
quality safe continuing care services from a high performing,
highly reliable Continuing Care system” within the next five
years.1
The focused work of CCQ is related to the key enablers to move
the CCQMF forward. Most specifically: governance; relationship
building; quality management cycle focusing on managing risk;
defining indicators of quality care; influencing a culture of
transparency, and; knowledge transfer / knowledge translation
tools.
Where we want to be: Where we are now:
CCQ Mandate2 Initiation Executing Monitoring & Controlling
Mandate Achieved (closing)
1. Develop and recommend for approval, the implementation plan
of the Continuing Care Quality Management Framework (CCQMF) for
Alberta Health Services (AHS) and contracted providers with the
intent to simplify and streamline quality improvement activities,
monitoring and reporting of Continuing Care services.
▲
2. Identify situations, internal or external to AHS that may
influence or impact the safety of individuals receiving continuing
care services: a. Identify, categorize and prioritize issues for
improvement that
impact quality of care and service or introduce risk within the
continuing care system in Alberta,
b. Seek out, monitor and respond to quality and safety issues,
and
c. Identify emerging knowledge and evidence, internal and
external trends or innovations that may impact the quality of care
and service leading to enhanced quality of life.
▲
3. Inform and support the development and implementation of key
strategies / initiatives that directly or indirectly influence the
ability to successfully provide high quality safe care and
service
▲ 4. Assess and inform the resourcing, infrastructure, processes
and
relationships required to facilitate continuous quality
improvement in order to achieve desired outcomes including quality
assurance, monitoring and auditing.
▲ 5. Prioritize strategies and initiatives that build capacity
in quality
assurance and quality improvement for effective and efficient
safe quality care.
▲ 6. Where appropriate, establish integrated working groups
to
achieve the mandate of the committee. Develop project plans (if
applicable), action plans, track progress and evaluate results.
▲ 7. Provide at least quarterly reports to QSEC that summarize
key
issues, risks identified, arising follow-up actions and key
quality indicator results for the previous quarter.
▲ Accomplishments and Highlights • Continuing Care Quality
Monitoring Recommendations developed by CCQ’s working group
(CC-Audits
Working Group). These Recommendations outlined the intent to
improve and streamline auditing and assurance functions (quality
monitoring) while at the same time increase Albertan’s confidence
in the continuing care system. The work included:
1 Continuing Care Quality Management Framework (June 2014),
pages 8 & 18 2 Continuing Care Quality Committee Terms of
Reference, Continuing Care Quality Management Framework (June
2014), Appendix 3
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Continuing Care Quality Committee
Annual Report to QSEC June 2015 - June 2016
CCQ Annual Report for QSEC June 2016 Page 3 of 20
o Analysis of the Current State of Quality Assurance and
Auditing in the Continuing Care System (review of auditing and
quality assurance functions, including Continuing Care Health
Service Standards, Continuing Care Accommodation Standards,
Accreditation and other quality monitoring and assurance functions,
current roles, responsibilities, duplication and areas of gaps. An
accompanying glossary with key auditing and quality assurance
definitions);
o Jurisdictional Review (related but not limited to
monitoring/audits, best practice reporting tools, performance
measure, complaints management process, and self- assessments);
o Guiding Principles for the Future State of Quality Assurance
and Auditing in Continuing Care to justifiably ground the proposed
recommendations;
o Vision development for the future state of auditing and
quality assurance in the Alberta Continuing Care System.
o This working group has completed its mandate • These
Recommendations were presented and approved at QSEC on December 17,
2015 and signed off
by the Deputy Minister of Health on February 12, 2016. • The CC
Quality Monitoring Recommendation implementation planning is
underway, in collaboration with
AHS and Alberta Health.
• Continuing Care Quality Indicator Recommendations developed by
CCQ’s working group (CC-Quality
Indicator Working Group). Progress of this work to-date
includes: o August 2014- March 2015, two Environmental Scans were
conducted and combined to form the
Consolidated CC-QIWG Quality Indicators and Public Reporting
Environmental Scan, included: Continuing care quality measurement
reporting mechanisms; and Jurisdictional scan of Quality
Indicators;
o August 2014- March 2015 CC-QIWG established Guidelines and
Criteria - In the identification and development of continuing care
quality indicators, there are two levels of agreed upon guiding
principles (i.e. Continuing Care Quality Management Framework
Principles) and criteria (i.e. Criteria to Assess the Maturity of a
Measure) that should be applied and met in decision making and
implementation. After applying the guiding principles and criteria,
the indicators are then classified by the Alberta Health Services’
(AHS) Risk Management Framework which helps to ensure comprehensive
risk identification and management;
o The AHS QHI agreed-upon definition for a Quality Indicator was
used in this work; o A Modified-Delphi methodology was employed to
consolidate and build consensus on which
measures were a good reflection of quality (as per the HQCA
definitions). This process resulted in filtering the initial 300
measures down to 50 measures. Quality Measurement Validation and
Identification Focus Groups were held to identify future concepts
of quality that should be measured in Alberta. Then two further
consensus-building meetings were held to discuss which of the 50
measures would be recommended by the CC-QIWG for public vs.
internal reporting. Lastly, RAI 2.0 Quality Indicator Expert panel
finalized the Near-Future Quality Indicator Public Reporting
Overview, twelve indicators are ready for detailed AHS public
reporting; three indicators are under development, and; three
indicators are not yet under development.
• These Recommendations were introduced to QSEC on February 25,
2016 and presented for approval to QSEC on April 28, 2016.
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• Continuing Care Quality Management Report – providing an
individual site/program-level report has been identified as a key
enabler outlined in the CCQMF (page 16-17). This is intended to
empower frontline care providers with timely access to
consolidated, easy to understand site-level quality information.
The intent is for all continuing care sites/programs (Home care-
Home Living; Designated Supportive Living; Long Term Care Facility
Living) to utilize this report to inform continuous quality
improvement, with an ability to share regularly with all staff and
bring forward to resident and family councils.
o This Quality Management Report (QMR) is not intended to be a
definitive measure of quality of care, but rather to showcase areas
of best practice where sites/programs are achieving above average
results and identify areas of potential risk where sites/programs
are below average.
o A pilot project with seven AHS LTC Facility sites in the North
Zone trialed the QMR from April1 to June 30, 2016. The pilot was
developed in collaboration with the North Zone. The learning from
this pilot will inform the next steps in how and when this will be
spread across continuing care.
• CCQ continues their established practice of a CCQ Meeting
Overview summary for wide general
circulation after each meeting. These overview summaries are
widely distributed via email, posted on AHS Insite
(http://insite.albertahealthservices.ca/9466.asp under Continuing
Care Quality Management Framework) and on the Continuing Care
Desktop (www.ccdweb.ca) for access by Continuing Care contracted
providers. As well, our associate members (i.e. ASCHA, ACCA)
further circulate the Overviews in their provincial newsletters and
post on their external websites.
• CCQ continues to value the commencing each meeting with a
personal story. These personal stories have created discussion with
intended take away key messages. The CCQ now has a record of
twenty-one personal stories (eleven in 2014/15 and ten 2015/16)
that could easily be used for case studies, review by other
stakeholders and have strengthen the focus strategies to meet the
mandate of CCQ (e.g. people powered approach, person-centred care,
patient first strategy).
• CCQ features a Quality Improvement story at the majority of
their meetings. These stories are required
to outline each step of the QI cycle following the AIW
framework: defining the opportunity / issue, analysis of the issue,
quality improvement steps, implementation and results. Summary hand
outs are included in the monthly CCQ overview for wide
distribution. CCQ now has sixteen documented QI stories (nine in
2014/15 and seven in 2015/16) which have been utilized to further
quality improvement across the continuing care system.
• The Public Members (patient / family advisors, health advisory
council members) are an integral part of the
CCQ and its work groups. They have established their
credibility, they are seen and valued as equal members. Their input
has driven critical conversations and has shifted direction of how
we are approaching decisions. Since the commencement of CCQ, we
have recorded over 400 volunteer hours from seven public
members.
• As per the mandate of CCQ to identify situations that may
influence or impact the safety of individuals
receiving continuing care services, CCQ members have been
engaged in the following: o HQCA presented the findings from the
2014-2015 LTC Family Experience Survey. Through
discussion at CCQ following this presentation, HQCA engaged with
CCQ in the development of a further measurement initiative pilot
from the survey finding. This initiative is an in-depth
http://insite.albertahealthservices.ca/9466.asphttp://www.ccdweb.ca/
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Continuing Care Quality Committee
Annual Report to QSEC June 2015 - June 2016
CCQ Annual Report for QSEC June 2016 Page 5 of 20
review with top-rated and lower-rated LTC facilities to identify
the differences in family experience and the learnings that could
be shared and inform continuous quality improvement.
o AHS 2014-2015 Continuing Care Health Services Standards Annual
Report was presented and discussed
o 2016 Continuing Care Health Services Standards and Information
Guide were presented by Alberta Health to gain an understanding of
the content
• The Continuing Care Quality Management Framework has been
extensively referenced (by permission from AHS) in the third
Canadian edition of the “Nursing Leadership and Management” by
Patricia Kelly and Heather Quesnelle, and published by Nelson
Education:
http://www.nelson.com/catalogue/productOverview.do?Ntt=Third+Canadian+Edtion%2C+Nursing+Leadership+and+management||1613151473716996899251087998831706590&N=197&Ntk=nelson%7C%7CP_EPI&Ntx=mode+matchallpartial
Future Direction CCQ members have acknowledged the need to
complete their initial focus of work relating to determining
quality indicators and a vision for quality assurance / auditing of
the continuing care system. Through the development of the CCQ work
plan, it has been identified that much of our future work has
interdependencies with other work that is going on that may
influence our work. There are plans underway to identify
opportunities for collaboration and partnering the work priorities
of the Seniors Health SCN, AH, Integrated Continuing Care Steering
Committee (ICCSC). Appendices
A. Revised CCQ Terms of Reference (for approval), CCQ approved
October 22, 2015 B. CCQ Membership C. CCQMF Logic Model Schematic
D. CCQ Work plan, living document
http://www.nelson.com/catalogue/productOverview.do?Ntt=Third+Canadian+Edtion%2C+Nursing+Leadership+and+management||1613151473716996899251087998831706590&N=197&Ntk=nelson%7C%7CP_EPI&Ntx=mode+matchallpartialhttp://www.nelson.com/catalogue/productOverview.do?Ntt=Third+Canadian+Edtion%2C+Nursing+Leadership+and+management||1613151473716996899251087998831706590&N=197&Ntk=nelson%7C%7CP_EPI&Ntx=mode+matchallpartial
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Continuing Care Quality Committee
Annual Report to QSEC June 2015 - June 2016
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Appendix A
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Appendix B Members Title, Division, Organization Chair Dr. James
Silvius Medical Director, Community, Seniors, Addictions and
Mental
Health (CSAMH), AHS Public Carla Helder Prairie Mountain Health
Advisory Council Judy Brown Resident / Client / Family Advisor
Linda McFarlane Resident / Client / Family Advisor Vacant Health
Advisory Council member Frontline Laureen Bolin CCHSS Auditor,
Central Zone Alberta Health Corinne Schalm Executive Director,
Continuing Care Branch Cheryl Whitten Executive Director,
Compliance and Monitoring Branch Pamela Renwick Acting Director,
Compliance and Monitoring Branch Suzanne Maisey Manager, Quality
Improvement, Continuing Care Branch Alberta Health Services Barbra
Lemarquand-Unich Executive Director, Integrated Seniors &
Community Care,
Calgary Zone Carol Anderson Executive Director, Seniors Health,
Edmonton Zone Carolyn Dryden Director, Quality Outcomes, Community,
Seniors, Addiction and
Mental Health (CSAMH) Claire McCrank Executive Director,
Community, Seniors, Addiction and Mental
Health (CSAMH) Colin Zieber Executive Director Senior Health,
South Zone Jeanine Kimura Director Performance & Risk
Management, Carewest on behalf
of Carewest and Capital Care (wholly owned subsidiary) Leanne
Dekker Senior Program Officer, Infection Prevention and Control
Lori Sparrow Executive Director, Seniors Health, Central Zone Scott
Fielding Senior Program Director, Seniors Health & Bone &
Joint Health
SCNs Robyn Maddox Executive Director, Seniors Health, North Zone
Ronda White Chief Audit Executive, Internal Audit / Enterprise
Risk
Management Trudy Harbidge CCQ Program Advisor, Senior Director,
Continuing Care
Quality, CSAMH Dr. Valerie Smith Medical Director, Seniors
Health, Central Zone Other Key Stakeholders Donalda Farwell
Area Director- Edmonton, Bayshore Home Health on behalf of
Alberta Continuing Care Association
Jeanette Leafloor Director of Member Relations, Alberta Seniors
Communities and Housing Association (ASCHA)
Raymond Cormie CEO, Father Albert Lacombe Home (Society) on
behalf of Alberta Continuing Care Association
Scott Baerg Senior Operating Officer, Covenant Health Vacant on
behalf of Seniors Housing Society of Alberta Representative As of
May 2016
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Appendix C
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Appendix D
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IntroductionAccomplishments and HighlightsFuture
DirectionAppendicesAppendix AAppendix BAppendix CAppendix D