FHT Vision
The Minto-Mapleton FHT (MMFHT) MMFHT will demonstrate excellence in delivering comprehensive, patient-centred rural primary care.
FHT Mission
The Minto-Mapleton FHT is a collaborative, interdisciplinary team of providers located in Minto (Palmerston, Harriston and Clifford) and Mapleton (Drayton). Our mission is to efficiently provide high quality, accessible, patient-centred primary care with a particular focus on chronic disease management and disease prevention to maximize health and well-being.
FHT Guiding Principles
The work of the Family Health Team (FHT) is guided by the following principles:
High-Level Strategic Directions for MMFHT
The Minto-Mapleton FHT (MMFHT) MMFHT will demonstrate excellence in delivering comprehensive, patient-centred rural primary care.
FHT Mission
The Minto-Mapleton FHT is a collaborative, interdisciplinary team of providers located in Minto (Palmerston, Harriston and Clifford) and Mapleton (Drayton). Our mission is to efficiently provide high quality, accessible, patient-centred primary care with a particular focus on chronic disease management and disease prevention to maximize health and well-being.
FHT Guiding Principles
The work of the Family Health Team (FHT) is guided by the following principles:
- Teamwork: We work in interdisciplinary teams of health care professionals to meet the needs of our patient population.
- Community partnerships: We work in collaboration with our community partners including other health care organizations and professionals.
- Realistic and Responsive: We strive to develop FHT programming and services based on the changing needs of our patients.
- Evidence-based practice: We are committed to developing and using evidence-based practice and continuous re-evaluation to guide our services and measure our results.
- Innovation: We use creative solutions that respond to local community and provider needs to achieve the FHT objectives.
- Research and education: Research and education opportunities are embraced and encouraged for all staff.
- Patient-centred: We encourage patient self-management by providing direction, education and support. Through this partnership we promote a culture of mutual trust and accountability.
High-Level Strategic Directions for MMFHT
Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario
Overview
The Quality Improvement Plan (QIP) has been developed to meet the requirements of the Excellent Care for All Act and to demonstrate to the community our commitment to quality, responsive, and accountable rural primary health care. The QIP aligns with the Minto-Mapleton Family Health Team's (MMFHT's) strategic directions and Annual Plan. The QIP, in addition to other quality improvement strategies, continues to play an important role in helping the FHT better understand our patients' experiences at the FHT with the goal of improving the quality of care and overall experience.
The Minto-Mapleton FHT's 2017/18 QIP will focus on three (3) quality dimensions: Effective Care, Patient-Centred Experience and Timely Care. The Effective Care quality dimension aims to improve cancer screening rates, specifically colorectal cancer and cervical cancer, and improve the rate of blood sugar testing for patients with diabetes. We will also be focusing on providing timely follow-up appointments post hospitalization for certain conditions. This year's plan continues to seek input from patients about their experiences with their primary care practitioner with the objective of maintaining our high performance of primary care involving patients in decision making about their care. The third quality dimension involves offering timely access to primary care when patients need an appointment. A variety of planned improvement changes will be initiated in 2017/18 and we will capitalize on tools available to us including our electronic medical record, Cancer Care Ontario's tools, patient surveys, Ministry of Health data and our own tracking processes.
The MMFHT has seven (7) practice sites spread across rural Minto-Mapleton and is located in the communities of Palmerston, Clifford, Harriston and Drayton.
The overall objectives of our Quality Improvement Plan include:
• Provide an organization focus across all practice sites on quality improvement;
• Identify measures/indicators and set targets for the organization to monitor and track process over time;
• Propose and implement planned improvement initiatives;
• Obtain meaningful input from our patients regarding their experiences at the FHT; and,
• Communicate findings, quality improvement progress and lessons learned.
The 2017/18 QIP is the 5th QIP that the Minto-Mapleton FHT has developed. We continue to remain committed to tracking our progress and working towards achieving our QIP objectives.
QI Achievements from the Past Year
Over the past year, the FHT implemented an electronic preventative care toolbar in our EMR for cancer screening. The toolbar was developed by a neighbouring FHT and our FHT was one of the pilot sites. Physicians were asked for their input and approval to implement. Based on the physicians' feedback, the toolbar removed bone mineral density (BMD). Now BMD has a separate toolbar. Currently, 7 of 8 physicians and all of our Nurse Practitioners are using the preventative care toolbar in the EMR for cancer screening. Feedback has been very positive and we are starting to see increases in our preventative care screening rates.
Population Health
Over the past year, the FHT has started working more closely with the local hospital trying to ensure patients who visit the hospital with COPD/asthma are linked with FHT programs, including our new pulmonary rehab program. Hospital Report Manager (HRM) e-Notifications received by our primary care providers in their EMR alert them of patients discharged from hospital. Using the e-Notifications, a list of patients with a diagnosis of COPD/asthma are reviewed by the FHT's COPD nurse and the hospital respiratory therapist to ensure the necessary testing is ordered and the patient is linked to FHT programs and services soon after their discharge. We are trying to prevent these patients from unnecessary repeated visits to our hospital.
Equity
The FHT continues to build on the number of services and programs it can offer to our rural residents through telemedicine. An excellent example of this is offering our COPD patients with access to a respirology clinic through telemedicine where respirologists from Toronto and Kitchener see our patients with a telemedicine nurse in their home community. This service allows our patients to receive services in a timely manner and removes the transportation barrier that many rural residents experience. Another great example of incorporating an equity lens into our quality improvement work is the implementation of E-consult with our physicians and nurse practitioners. E-consult allows our providers to securely correspond with specialists regarding patient situations/questions and receive helpful guidance from a specialist in a timely manner. Half of our providers are now using E-consult.
Integration and Continuity of Care
This year's QIP continues to recognize the importance of health care partners working together to create smoother transitions for our patients. The FHT will continue to monitor our performance on the percentage of patients who saw their primary care provider (physician or nurse practitioner) within 7 days after discharge from hospital for selected health conditions. We are now capitalizing on a more consistent use of the e-Notification feature of Hospital Report Manager to track our patients who are admitted and discharged from hospital, and who need a primary care visit within seven days. We also continue to use the EMR tracking process we developed for our patients who see their Nurse Practitioner post-hospital discharge.
Access to the Right Level of Care - Addressing ALC Issues
Minto-Mapleton FHT is helping to ensure patients have access to the right level of care by supporting Alternative Level of Care (ALC) initiatives in our community. For example, the FHT is an active participant in Health Links/Community Outreach Initiative which includes various partners working together to develop coordinated care plans for complex patients. Through the development and sharing of coordinated care plans, programs and supports are being put in place to help residents stay in their own homes.
At the sub-regional level, the FHT is working in partnership with other Rural Wellington Health Advisory Partners on a Collaborative QIP. Integrate Care/System Coordination is a key focus of the Collaborative QIP that involves a commitment between the rural Wellington Hospitals, all of the rural Wellington Family Health Teams and the Waterloo Wellington Community Access Centre (CCAC). CCAC Care Coordinators are being aligned with primary care providers (physicians and nurse practitioners) in Minto-Mapleton with the goal of reducing unplanned re-admissions to the local hospital.
Engagement of Clinicians, Leadership & Staff
The Family Health Team has an active Quality Committee that meets regularly to review progress on the Quality Improvement Plan (QIP) and to participate in the development of the annual QIP. The Committee is comprised of clinical and administrative staff, management, and two physicians including the FHT's Medical Lead. Members of the Committee worked together to establish quality improvement initiatives, goals and commitments for the organization for 2017/18. Throughout the year, members of the Quality Committee will keep FHT Staff and practice sites up to date by providing progress reports in the FHT-bit newsletter and verbal updates at meetings. The Medical Lead and Executive Director regularly report progress on our QIP to the FHT Board.
Resident, Patient, Client Engagement
The main vehicle where we engage our patients and their caregivers in our Quality Improvement work is through our patient surveys in each of our physicians' and NPs' offices. We will continue with patient survey distribution in 2017/18 at each of our practice sites. We will also reach out to patients and caregivers who attend some of our FHT programs in terms of survey distribution and we use the FHT's website to engage patients/caregivers. In 2017/18, we are going to pilot using tablets at one of our sites for the patient survey. Results from the patient surveys are discussed at our Quality Committee meetings, FHT Board Meetings, FHO User Group Meetings and FHT Staff Meetings.
Staff Safety & Workplace Violence
The Minto-Mapleton Family Health Team is committed to building and preserving a safe working environment for its staff. The FHT assesses risk factors in the workplace to identify workers who may be exposed to violence. In conjunction with staff, the FHT's health and safety representatives regularly review our Violence Policy and Program to minimize or eliminate the risks of violence in the workplace. Any incidents of workplace violence are reviewed by the FHT's health and safety representatives to ensure concerns have been dealt with and to make recommendations to reduce or eliminate risk of violence. The FHT is also committed to training and informing staff on the contents of the Violence Policy and Program to ensure that staff are knowledgeable of the risk factors and how to eliminate or respond to violent situations.
Contact Information
Shirley Borges, Minto-Mapleton FHT Executive Director. sborges@mmfht.ca 519 638 2110
Other
It seems logical that our quality improvement work related to our QIP aligns with AFHTO's Data to Decisions (D2D) work. This avoids duplication of efforts and provides a coordinated quality improvement focus for our FHT.
The Quality Improvement Plan (QIP) has been developed to meet the requirements of the Excellent Care for All Act and to demonstrate to the community our commitment to quality, responsive, and accountable rural primary health care. The QIP aligns with the Minto-Mapleton Family Health Team's (MMFHT's) strategic directions and Annual Plan. The QIP, in addition to other quality improvement strategies, continues to play an important role in helping the FHT better understand our patients' experiences at the FHT with the goal of improving the quality of care and overall experience.
The Minto-Mapleton FHT's 2017/18 QIP will focus on three (3) quality dimensions: Effective Care, Patient-Centred Experience and Timely Care. The Effective Care quality dimension aims to improve cancer screening rates, specifically colorectal cancer and cervical cancer, and improve the rate of blood sugar testing for patients with diabetes. We will also be focusing on providing timely follow-up appointments post hospitalization for certain conditions. This year's plan continues to seek input from patients about their experiences with their primary care practitioner with the objective of maintaining our high performance of primary care involving patients in decision making about their care. The third quality dimension involves offering timely access to primary care when patients need an appointment. A variety of planned improvement changes will be initiated in 2017/18 and we will capitalize on tools available to us including our electronic medical record, Cancer Care Ontario's tools, patient surveys, Ministry of Health data and our own tracking processes.
The MMFHT has seven (7) practice sites spread across rural Minto-Mapleton and is located in the communities of Palmerston, Clifford, Harriston and Drayton.
The overall objectives of our Quality Improvement Plan include:
• Provide an organization focus across all practice sites on quality improvement;
• Identify measures/indicators and set targets for the organization to monitor and track process over time;
• Propose and implement planned improvement initiatives;
• Obtain meaningful input from our patients regarding their experiences at the FHT; and,
• Communicate findings, quality improvement progress and lessons learned.
The 2017/18 QIP is the 5th QIP that the Minto-Mapleton FHT has developed. We continue to remain committed to tracking our progress and working towards achieving our QIP objectives.
QI Achievements from the Past Year
Over the past year, the FHT implemented an electronic preventative care toolbar in our EMR for cancer screening. The toolbar was developed by a neighbouring FHT and our FHT was one of the pilot sites. Physicians were asked for their input and approval to implement. Based on the physicians' feedback, the toolbar removed bone mineral density (BMD). Now BMD has a separate toolbar. Currently, 7 of 8 physicians and all of our Nurse Practitioners are using the preventative care toolbar in the EMR for cancer screening. Feedback has been very positive and we are starting to see increases in our preventative care screening rates.
Population Health
Over the past year, the FHT has started working more closely with the local hospital trying to ensure patients who visit the hospital with COPD/asthma are linked with FHT programs, including our new pulmonary rehab program. Hospital Report Manager (HRM) e-Notifications received by our primary care providers in their EMR alert them of patients discharged from hospital. Using the e-Notifications, a list of patients with a diagnosis of COPD/asthma are reviewed by the FHT's COPD nurse and the hospital respiratory therapist to ensure the necessary testing is ordered and the patient is linked to FHT programs and services soon after their discharge. We are trying to prevent these patients from unnecessary repeated visits to our hospital.
Equity
The FHT continues to build on the number of services and programs it can offer to our rural residents through telemedicine. An excellent example of this is offering our COPD patients with access to a respirology clinic through telemedicine where respirologists from Toronto and Kitchener see our patients with a telemedicine nurse in their home community. This service allows our patients to receive services in a timely manner and removes the transportation barrier that many rural residents experience. Another great example of incorporating an equity lens into our quality improvement work is the implementation of E-consult with our physicians and nurse practitioners. E-consult allows our providers to securely correspond with specialists regarding patient situations/questions and receive helpful guidance from a specialist in a timely manner. Half of our providers are now using E-consult.
Integration and Continuity of Care
This year's QIP continues to recognize the importance of health care partners working together to create smoother transitions for our patients. The FHT will continue to monitor our performance on the percentage of patients who saw their primary care provider (physician or nurse practitioner) within 7 days after discharge from hospital for selected health conditions. We are now capitalizing on a more consistent use of the e-Notification feature of Hospital Report Manager to track our patients who are admitted and discharged from hospital, and who need a primary care visit within seven days. We also continue to use the EMR tracking process we developed for our patients who see their Nurse Practitioner post-hospital discharge.
Access to the Right Level of Care - Addressing ALC Issues
Minto-Mapleton FHT is helping to ensure patients have access to the right level of care by supporting Alternative Level of Care (ALC) initiatives in our community. For example, the FHT is an active participant in Health Links/Community Outreach Initiative which includes various partners working together to develop coordinated care plans for complex patients. Through the development and sharing of coordinated care plans, programs and supports are being put in place to help residents stay in their own homes.
At the sub-regional level, the FHT is working in partnership with other Rural Wellington Health Advisory Partners on a Collaborative QIP. Integrate Care/System Coordination is a key focus of the Collaborative QIP that involves a commitment between the rural Wellington Hospitals, all of the rural Wellington Family Health Teams and the Waterloo Wellington Community Access Centre (CCAC). CCAC Care Coordinators are being aligned with primary care providers (physicians and nurse practitioners) in Minto-Mapleton with the goal of reducing unplanned re-admissions to the local hospital.
Engagement of Clinicians, Leadership & Staff
The Family Health Team has an active Quality Committee that meets regularly to review progress on the Quality Improvement Plan (QIP) and to participate in the development of the annual QIP. The Committee is comprised of clinical and administrative staff, management, and two physicians including the FHT's Medical Lead. Members of the Committee worked together to establish quality improvement initiatives, goals and commitments for the organization for 2017/18. Throughout the year, members of the Quality Committee will keep FHT Staff and practice sites up to date by providing progress reports in the FHT-bit newsletter and verbal updates at meetings. The Medical Lead and Executive Director regularly report progress on our QIP to the FHT Board.
Resident, Patient, Client Engagement
The main vehicle where we engage our patients and their caregivers in our Quality Improvement work is through our patient surveys in each of our physicians' and NPs' offices. We will continue with patient survey distribution in 2017/18 at each of our practice sites. We will also reach out to patients and caregivers who attend some of our FHT programs in terms of survey distribution and we use the FHT's website to engage patients/caregivers. In 2017/18, we are going to pilot using tablets at one of our sites for the patient survey. Results from the patient surveys are discussed at our Quality Committee meetings, FHT Board Meetings, FHO User Group Meetings and FHT Staff Meetings.
Staff Safety & Workplace Violence
The Minto-Mapleton Family Health Team is committed to building and preserving a safe working environment for its staff. The FHT assesses risk factors in the workplace to identify workers who may be exposed to violence. In conjunction with staff, the FHT's health and safety representatives regularly review our Violence Policy and Program to minimize or eliminate the risks of violence in the workplace. Any incidents of workplace violence are reviewed by the FHT's health and safety representatives to ensure concerns have been dealt with and to make recommendations to reduce or eliminate risk of violence. The FHT is also committed to training and informing staff on the contents of the Violence Policy and Program to ensure that staff are knowledgeable of the risk factors and how to eliminate or respond to violent situations.
Contact Information
Shirley Borges, Minto-Mapleton FHT Executive Director. sborges@mmfht.ca 519 638 2110
Other
It seems logical that our quality improvement work related to our QIP aligns with AFHTO's Data to Decisions (D2D) work. This avoids duplication of efforts and provides a coordinated quality improvement focus for our FHT.
