Excellence through Quality Improvement Project (E-QIP)
Since 2016, the Excellence through Quality Improvement Project has been working with the community mental health and addictions sector to enhance the ability of agencies within this area of healthcare to understand and apply quality improvement methods. E-QIP has offered QI project coaching support to agencies, an extensive training and education program and developed an online community of practice to continue that is a portal for QI resources and sharing.
E-QIP is a collaborative initiative of Addictions and Mental Health Ontario (AMHO), Canadian Mental Health Association (CMHA Ontario), and Health Quality Ontario (HQO). Together these organizations are supporting Ontario’s community mental health and addiction service providers to make care better by enhancing a sector-wide culture of Quality Improvement (QI).
Here is graphic of the key accomplishments of this program over the first 18 months:
What’s next for E-QIP:
E-QIP will continue working with organizations on:
- Building a common understanding of quality improvement in the community mental health and addiction sector
- Gaining an understanding of the full range of quality initiatives that exist in the sector, and promote the spread of promising practices across mental health and addictions provider agencies
- Building capacity within the sector to utilize multiple data sources for improving and planning, with particular focus on provincial priority data sources / elements such as the OCAN, OPOC and Mental Health and Addictions Scorecard
- Sharing quality knowledge and building capacity across our sector organizations
- Building sustainability of quality improvement capacity with sector organizations
- Laying the groundwork so that when the government introduces expectations, the sector is ready and leading the performance measurement and reporting
- Ensuring alignment with other quality improvement initiatives in Ontario including Quality Matters: Realizing the Excellent Care for All Act and HQO
Excellence through Quality Improvement Project expanding its focus
on improved client care and experience
Read more about E-QIP expanding focus
Excellence through Quality Improvement Project expanding its focus on improved client care and experience
(Toronto, Sept. 12, 2019) – The Excellence through Quality Improvement Project (E-QIP), a provincial initiative that works to enhance the quality of care in the community-based mental health and addiction sector, is expanding and adapting its focus on improving client care and experience.
Since March 2016, E-QIP has provided leadership and capacity building in the community mental health and addiction sector by promoting and supporting quality improvement, measurement and the use of data in decision-making. Led by Addictions and Mental Health Ontario (AMHO) and Canadian Mental Health Association, (CMHA) Ontario Division, going forward E-QIP will be delivered in close partnership with the Provincial System Support Program (PSSP) at the Centre for Addiction and Mental Health (CAMH).
The main objectives of this new phase of E-QIP will be to improve client outcomes and client experiences of care in the community-based mental health and addictions sector. It will accomplish this work by:
- Increasing the understanding and use of quality improvement methodologies in mental health and addiction care
- Increasing data literacy (collecting, analyzing, using data)
- Working towards improvement in key domains of quality and spreading promising practices
- Supporting a culture of quality improvement learning and mentorship across the province
“Leveraging the existing expertise and past efforts of E-QIP, this new phase of the project will deliver cost-effective results that are aligned with the province’s approach to mental health and addictions care,” said Michael Dunn, CMHA Ontario’s Director of Quality Improvement and E-QIP co-lead. “Together, we will work collaboratively to support the Ministry of Health’s vision for a data-driven approach to improving care in the community mental health and addiction sector as part of Ontario Health Teams.”
“Addictions and Mental Health Ontario, CMHA Ontario and PSSP will work closely to evolve the E-QIP model to encompass a greater focus on common system priorities, the implementation of standardized tools (e.g. OPOC, OCAN, GAIN), and the use of data to support ongoing quality improvement and performance management,” said Debbie Bang, AMHO’s Director of Quality Improvement and E-QIP co-lead. “These efforts will result in better experiences and outcomes for clients and a more connected and efficient system overall.”
“PSSP is very excited to work with our colleagues at CMHA Ontario and AMHO as this new phase of E-QIP rolls out to the mental health and addiction sector,” said Derek Chechak, Manager of Implementation with PSSP. “In fitting with the objectives of this work, we are pleased to bring our experience implementing the Ontario Perception of Care Tool for Mental Health and Addiction as well as the Staged Screening and Assessment process, as these projects demonstrate the importance of standardizing quality care and using data to improve care.”
Since it began in 2016, E-QIP has improved sector capacity through quality improvement and data coaching, training and education sessions, and a dedicated community of practice. In the second year of the initiative, it focused on encouraging the uptake of standardized assessment tools and provincial data sets and addressing system priorities such as access, client experience and effectiveness. To date, almost 100 agencies have participated in E-QIP coaching, and through this, the program has collected valuable insights into the use of existing provincial data sets and assessment tools.
To learn more about E-QIP, search the hashtag #EQIPON.
- Eighty-one per cent of agencies that have participated in E-QIP to date indicated they would be interested in participating in the future.
- Currently, 60 agencies have requested involvement in future E-QIP coaching, with an additional 30 agencies requesting board member coaching.
- Following a data and QI coaching cohort in March 2019, 100 per cent of participants surveyed said E-QIP facilitated improvements to their organizational culture and was helpful for implementing quality improvement practices within their organizations.
About Canadian Mental Health Association, Ontario
Canadian Mental Health Association (CMHA), Ontario is a not-for-profit, charitable organization funded by the provincial Ministry of Health and Long-Term Care. We work to improve the lives of all Ontarians through leadership, collaboration and continual pursuit of excellence in community-based mental health and addictions services. Our vision is a society that embraces and invests in the mental health of all people. We are a trusted advisor to government, contributing to health systems development through policy formulation and recommendations that promote positive mental health. Our 30 local CMHA branches, together with community-based mental health and addictions service providers across the province, serve approximately 500,000 Ontarians each year.
About Addictions and Mental Health Ontario
Addictions and Mental Health Ontario (AMHO) represents 200 addiction and mental health organizations in Ontario. Our members provide services and supports that help Ontarians across the province with their recovery, including community-based counselling and case management, peer support and consumer run businesses, residential treatment, withdrawal management, supportive housing and hospital-based programs. As the collective voice of our members, we provide leadership and engage partners to build a comprehensive and accessible system of addiction and mental health care, and improve the well-being of individuals, families and communities in Ontario. We do this through policy work, advocacy initiatives, service development, knowledge exchange, education offerings and quality improvement work.
About the Provincial System Support Program
The Provincial System Support Program (PSSP) at the Centre for Addiction and Mental Health works with communities, service providers and other partners across Ontario to move evidence to action to create sustainable, system-level change. With offices in Toronto and across the province, PSSP is on the ground, collaborating with stakeholders to build a better system through our work in implementation, knowledge exchange, evaluation and data management, and health equity and engagement. Visit www.camh.ca/pssp to learn more.
Through the provincial E-QIP initiative, community mental health and addiction agencies across Ontario are realizing the value of incorporating quality improvement to make their services more accessible for those who need them most.
QI and data coaches associated with Excellence in Quality Improvement Project have been deployed to help participating agencies identify a key service or quality issues to address with QI principles. The E-QIP team is partnering with these organizations to create solutions that enhance program effectiveness for the benefit of clients and their families.
E-QIP is pleased to present the following project profiles:
Jean Tweed: Increasing Access to Primary Care for Outreach Clients
St. Jude Community Homes: Coordinated Discharge Planning
- QI coach: Tara McKendrick
- Data Coach: Abel Gebreyesus
Project Overview St. Jude Community House is a supportive housing provider in Toronto with 92 units open 7 days a week. Support staff are onsite 12 hours each weekday, and eight hours on weekends, with a caretaker on call 24/7. Although transitions in health care are often where continuity of care falls through the cracks, the transition to supportive housing – which isn’t well understood by most health care providers – is even more challenging. For the staff at St. Jude’s Community Homes, they saw this lack of coordinated discharge planning between them and the hospital as more than a nuisance – it was causing safety issues for them and their clients. When the opportunity to get involved in the EQIP initiative came up, St. Jude’s was quick to respond seeing this as an opportunity to tackle a long-standing problem. According to Shannon McCauley, Project Lead, the QI tools they learned how to use through the EQIP project were incredibly helpful in “getting past the frustration that we can’t effect change in the hospital, and got us focused on what we can do.” St. Jude’s used the Fishbone diagram as their diagnostic tool, and it “created much needed clarity to our known problems,” explains Shannon. The root causes were identified as:
- Lack of Education and awareness of St. Jude and supportive housing within hospitals and other health service providers
- Lack of clarity of staff role and gaps with access to supports
- No central system for staff to receive phone calls after hours
- It’s not simple for outside support and residents to access staff if their assigned worker is off site
Using a driver diagram, they were able to dig deeper and begin identifying change ideas. Their next steps are to start testing their change ideas using PDSA– Plan, Do, Study, Act – cycles, and creating run charts to monitor their process measures. One of the biggest change ideas is creating a single point of access for St. Jude’s staff, which they will be testing through a PDSA starting with one Health Service Provider. And they’ve identified a few more:
- Creation of a flow chart for staff when a resident is hospitalized
- Include a line in the job description for resource staff to answer the general support phone line
- Create scripts for answering the phone, redirecting calls and voice mail messages directing callers to new numbers
By streamlining the process for health service providers and clients to contact the staff at St. Jude’s Community House, clients will experience an easier transition back to their homes, and hopefully reduce the rates of re-admission to hospital because of the lack of follow up care. Through their involvement with EQIP, St. Jude’s is hoping to make a habit of quality improvement.
St. Stephen’s Community House: Reduce Corner Drop-in Restrictions
- Lack of consistent model for reintegration
- Staff perception
- Equitable treatment of all clients
Next, they used the 5 whys tool to dig deeper into the issue, and identify change ideas. “For us, the QI tools were extremely helpful in getting past the assumption that the only solution was more resources,” explains Caroline Jemmott, Manager of Drop-in and Housing Services. “We learned a lot from the data, and were able to identify innovative change ideas.” St. Stephen’s put their focus on
- Applying consistent restrictions:
- Collecting data and incident information
- Streamlining the reintegration process, including assigning dedicated staff to this
- Implementing a restorative justice model
Through an analysis of the data, they were able to debunk the myth that there were a high number of repeat offenders, and they were able to commend themselves for being more consistent than they thought about restrictions for violence. The St. Stephen’s Community House Corner Drop-in QI project is an important reminder that there are innovative solutions to some of the most challenging problems. For those people who use the Corner Drop-in, having a better, more consistent process for managing service restrictions means they will have more access to a warm meal and community supports. For this highly vulnerable population, that could be the difference between life and death.
CMHA Nipissing: Improving Client Referral to Decision Notification
- QI coach: Laura Daly-Trottier
- Data Coach: Alexandra Clement
Project Overview It can take a lot of effort for someone with a mental health issue to reach out for the services they need. So when they do, they expect the services to be responsive. It’s hard to wait 1.5 to four months to find out whether you’ve been accepted into the service. CMHA Nipissing Regional Branch recognized that the time it took them to notify a client about whether they would be accepted by the Bridges Trusteeship Service was too long, and inconsistent at best. For them, the EQIP initiative was the opportunity to do something about this problem. To tackle a process challenge, starting with a process map was an obvious first step. It was a highly visual way to see what was happening between the client’s first point of contact, and when the Bridges Service was reconnecting with them to notify them of acceptance or non-acceptance. The map showed a total of 16 steps, of which only two were value added steps. Based on their findings, they decided to dig deeper and truly understand the client experience using two Experience-Based Co-Design (EBCD) methods – a questionnaire with 15 clients and in-depth interviews, captured on video, with three to 5 clients. According to Daly-Trottier, “We want to be certain we would be focusing our improvement efforts on the right areas.” From these two activities, they’ll create an Emotion Map, showing the clusters of positive and negative emotions and what triggered those emotions. Once their EBCD activities are complete, they’ll take the findings from both the staff process and the client process to guide their change ideas, to focus on improvements that will make this service better for clients. Through their QI work so far, it’s clear that this program addresses an expressed client need in the community. Adding to the pressure on the program is that no other agency offers voluntary trusteeship services. Through the EQIP project, CMHA Nipissing Region Branch is now tackling the root causes including the fact that the program is not user-friendly, and that data entry can’t be done in a meeting room when meeting with a client. And by using the QI tools, the team was able to break down the problem into bite-size pieces, and they have the tools to make sure the solutions are effective before fully implementing them. “Our opportunity to be involved in the EQIP project is a game changer.” The EQIP project isn’t only going to improve the waiting time for clients who have applied for the Bridges Trusteeship program. According to Jeanette Geisler, an EQIP team member at CMHA Nipissing, “Our opportunity to be involved in the EQIP project is a game changer for CMHA Nipissing. We are applying the skills and the tools we learned throughout the organization – it’s creating a shift and focus, and is embedding QI in a number of areas, like an admin assistant using a tally sheet for time cards.” The team is now using these tools to work through the larger changes happening at the branch. And that means improved services for people with mental health and addiction problems in Nipissing Region. “We will use these tools for a long time.”
Madison Community Services: Quality Improvement of Case file Completion
- QI coach: Linda Saunders
- Data Coach: Abel Gebreyesus
About Madison Madison Community Services is a multi-service agency that supports people with chronic mental health and addiction issues. Madison began in 1977 as one of the first community-based supportive housing agencies in the province. Its first supportive housing property was on Madison Ave, in downtown Toronto – which was how the community based agency it got its name. Madison recognizes the important role that completed documentation plays in ensuring that clients are able to reach their goals. Through a review of client files, it became clear that timely completion of Ontario Common Assessment of Need (OCAN) and case notes was an issue and would affect this part of service delivery. Beginning with a process map to understand the steps in the data collection process, the Madison team was able to understand documentation flow that followed a client’s service path and prioritize actions. The project team worked with their coaches to gather data as a next step. This has been a bit challenging due to the structure of and reports available in the IT system. However, the team has continued to work to get accurate estimates and definitions of documentation completion rates. Using the fishbone diagram, a larger team was able to begin identify root causes that interfere with timely documentation. Through that same process they used a “dotmocracy” system to vote on and identify the most common problems. They then translated that to a Pareto chart, to see the frequency and detail of the root causes. One issue that Madison identified as key to moving forward with the project was the definition of completion, particularly of the OCAN as this is one of the first steps in developing recovery plans and completing relevant case notes. Ultimately, they developed a four-part definition, which they expect will help in narrowing in on change ideas to target this problem. “Although we started with a narrow focus, in working with our coach, we expanded it a bit. However, every time we dig a bit deeper, we discover new issues that are interconnected”. This speaks to the importance of a robust diagnostic process in ensuring a successful and sustainable QI projects. From the Executive Director’s perspectives, Jean Stevenson, “The EQIP project and tools were really helpful for us. It was a real eye-opener for us to identify some of the challenges we have. We believe this learning will have a lasting impact on us and our services and ultimately improve our services significantly and better serve our clients.”
MacKay Manor: Increasing Referrals from Emergency Departments to Community Withdrawal Management Services
- Problem of readmission versus getting treatment
- Lack of knowledge and understanding of the community-based addiction treatment services
The team worked to uncover the root causes, using the Fishbone Diagram that examined places, providers, people, processes, procedures and policies. They then used a driver diagram to explore even further. The team then used the PDSA Cycle – Plan, Do, Study, Act – to test three change ideas:
- Attending morning huddles in the ER
- Send introduction letters to four hospitals
- Making random visits to the ER
The team found that the first two ideas were very effective, while random visits to ERs were completely ineffective. The CWMS team have worked extensively with one of the five ERs in their region, and through that single partnership, the team has seen a notable increase in referrals. The team is now building on the lessons learned from that first ER as they begin working with a second ER. From that one hospital, the team has had nine referrals. It’s a huge step forward over the number of referrals – zero – that they received over the same period last year. Cheryl Chute, the project lead, celebrated the team’s achievement. “I never realized that doing small things would make such a big impact,” she said. CWMS’s QI coach, Laura Daly-Trottier, was equally impressed by the team’s vision and perseverance. “They took the QI bull by the horns and they really used the concepts to make a difference. One of their ideas didn’t work, but that didn’t stop them. They kept pressing forward.” The CWMS EQIP project tackles a very significant system challenge: the “emergency room revolving door.” They’ve already made a difference for nine people who wouldn’t have been referred to withdrawal services at the same time last year. And we know this is just the beginning.
TEACH: Mississauga Halton Region Enhancing & Sustaining Peer Support Initiative funded and supported by the Mississauga Halton LHIN
- QI coach: Laura Daly-Trottier
Project Overview Peer support is not the first thing that comes to mind when we think about what we can do to improve the experience and outcomes for those accessing mental health and addiction services. But the Mississauga Halton LHIN’s System Integration Group for Mental Health and Addictions (SIGMHA) identified peer supports as the highest priority for addressing mental health and addiction service needs in their region in 2014/2015. The MH LHIN’s Enhancing and Sustaining Peer Support initiative, led by Support and Housing-Halton through its peer support initiative: TEACH (Teach Empower Advocate Community Health) has been in place since 2015 to address this priority area. Widespread throughout the MH LHIN area, the initiative has 40 paid peer positions embedded across 11 accredited LHIN-funded health care organizations including hospitals and community providers. The initiative is making a difference in the health outcomes for those living with mental health and addictions. It provides hope, empowerment and self-determination to individuals, supports recovery-oriented practice within health care organizations through consultation and conversations with co-workers, peer workers, peer supervisors and leaders within the partner health care organizations. Altogether, this helps create workplaces focused on personal self-care and wellness. The team knows that peer support is not always well understood within the formal walls of the health care system. The TEACH team immediately recognized the opportunity of getting additional QI support from E-QIP’s province-wide initiative to enhance their work to increase the understanding of the value of peer support. “It was a perfect opportunity for us to add more QI bench-strength and knowledge to our project,” said Betty-Lou. “Equally important, it was an opportunity to collaborate with like-minded organizations across Ontario, and even showcase our work so that many more people living with mental health and/or addiction issues in our province can benefit from peer support as part of their formalized health care interaction. Being involved with E-QIP has given the work even more focus.” They’ve learned ways to use QI mechanisms such as Root Cause Analysis, Fishbone Diagram, The 5 Whys and Pareto Charting to identify their problem statement, root cause, change ideas, triangulate scope / boundaries, create an aim statement, identify key milestones/ timelines and develop barriers and mitigation strategies. All these tools led them to develop their E-QIP Project Charter. Through this work, ultimately, everyone agreed that the root cause of the re-occurring issue of clarity and definition of peer support roles. Peer Support is based on values including: hope and recovery; self-determination; empathetic and equal relationships; dignity, respect and social inclusion; integrity, authenticity and trust; health and wellness, and; lifelong learning and personal growth. They want to determine the degree to which these values are perceived to be present by people receiving peer services. The results of this will drive additional QI processes regarding trainings, support, organizational culture and philosophy shifts to foster values based peer support. As Laura explains, “They have applied the tools in a practical way, sharing their new found knowledge with others helping to increase the capacity for quality improvement in the sector.” Their work has already inspired comments like this from a person who received peer support, “Peer support was a life saver for me. It was the first time that I felt someone understood me from over a dozen hospital admissions where there had been no peer workers.” With their continued focus, their work will reach more people with mental health and addiction problems.
CMHA Middlesex: Improving Access to Service
- QI coach: Linda Saunders
- Data Coach: Nicole Adkin
Project Overview Seeking treatment is often a big step for someone dealing with a mental health problem. Access to services starts with an assessment, followed by a wait for services to start. At Canadian Mental Health Association Middlesex, they knew their wait times from assessment to service initiation were too long. With the support from the EQIP initiative, CMHA Middlesex hopes to reduce the ‘avoidable’ wait times significantly. Run charts for 2015 and 2016 were done to look at the average days waited between assessment and when the client first started receiving services. In 2015, it ranged from 150 days to up to 225 days. In 2016, it was as low as less than 100 days and as high as 250 days. The team then used a Fishbone diagram, the 5 Whys tool and a Driver Diagram to identify root causes. Based on what they learned through the diagnostic tools, they developed a future state process map so that the entire team could visualize where they were going and what they were aiming for. Not only will this reduce the wait time for services, it will also improve the patient experience and the continuity of care. The biggest change that is being implemented as a result of this QI project is that CMHA Middlesex is creating a new service model. Specifically, intake workers will become case managers which will help in avoiding the need for clients to tell their story multiple times, create more connection to the crisis service and have seamless follow up with those accessing those services. Not only will this reduce the wait time for services, it will also improve the patient experience and the continuity of care. CMHA Middlesex hopes to spread this shift in job function even further, to improve more services for clients. CMHA Middlesex experienced some resistance to the idea of a QI project at the outset. But that shines the light on an important lesson, explains Jennifer Dowsett, “There was some staff resistant at first, but by participating in the process, we were able to build trust and cooperation, and we’re pleased that our team is on board now.” Now they hope to spread their learning across the organization.
Ottawa Salus: Running Group– The Client Experience
- QI coach: Linda Saunders
- Data Coach: Nicole Adkin
Project Overview Running is hard. But Ottawa Salus Support Housing and Mental Health Services, that fact doesn’t deter the Recreation Therapy staff who offer a Running Group as a positive recovery focussed program for a small number of clients. Although there is anecdotal information and examples of the importance and impact of the running program on participant’s recovery, there has never been a formal way to capture data on the client experience. The EQIP initiative is about to change that. The Ottawa Salus group used many of the EQIP tools to better understand the situation, and identify the root cause analysis. Although their focus is to get more participants in the running group, and for participants to maintain running as a key component of their recovery longer term, they knew they had to start one step behind that – to collect data about the running experience. The lightbulb moment for this team came early on, when they were at an EQIP training session. It was then that we realized we needed to get feedback directly from the participants to inform their improvement focus. They used Experience-Based Co-Design methods, starting with an emotions statement for each step in the process. “Seeing the enthusiasm from the team when they heard the feedback from participants, was really inspiring and encouraging for the RTs who oversee the running group,” explains Joanne Cormack, Project Lead. To see and hear the progress from the beginning of the process to the end, gave insight to those running the group. After identifying the root causes of why running is hard, the team was able to identify some change ideas including – taking training slowly, having previous runners talk to new group members, providing education sessions on key techniques important for running, offering flexibility in running schedules, among others. As their next step, the results will be presented back to the participants, and together they will focus their improvement work on the ones that will help them work towards their next goal: how to increase participation in the group, and increase the number of people who sustain running long term.
Oak Centre Clubhouse: Improving Integration of OCAN Data into Recovery Plans
- QI coach: Tara McKendrick
- Data Coach: Andrew Span
Project Overview Oak Centre Clubhouse is a community mental health program serving people in the Niagara Region who have mental health problems. They support people to go back to work and school, provide assistance with legal/family/transportation/housing issues, and help people navigate mental health services such as the Ontario Disability Support Program, Ontario Works and Canada Pension Plan. In looking through the recovery plans for Oak Centre members, they realized that many were missing the important information and insights gained through the OCAN process. Oak Centre knows just how important it is for an OCAN to be completed for each member as it improves their ability to be successful in their recovery. OCAN is a consumer-directed tool used in Ontario that has been proven to support the recovery process. It creates a full client profile, helps identify barriers to recovery and supports the member and staff to create plans to address those barriers. Oak Centre used the Fishbone and Pareto Chart as their diagnostic tools to analyze the root causes of why OCAN information is not included in recovery plans. It became clear that there were competing priorities between unit and individual needs, lack of staff training and supervision, and a lack of technology infrastructure. This led the team to identify three high priority items for change:
- Prioritization and timing
- Data entry and technological capability
- Lack of supervision and accountability
Using these three items, the team worked through a driver diagram to identify the change ideas, which included developing a staff OCAN schedule and assessment reminder, using a staff mentorship system, offer regular OCAN training for staff and making changes to maximize space and flow, to name a few. Oak Centre has created a list of questions, that will now be tested using PDSA – Plan, Do, Study, Act – cycles. This will allow them to test their change ideas, and adapt them along the way. According to Sylvie Morgan, co-lead of the EQIP project, “For us this was unfamiliar territory, and the EQIP project gave us the tools we needed to identify change opportunities. The whole process helped us challenge our preconceived notions, which wouldn’t have happened otherwise.” As a result of Oak Centre’s participation in the EQIP initiative, more members will have completed OCANs, which will ultimately improve their quality of life and recovery process. This project is a great example of how having access, understanding and skills to use QI tools can make a difference in their member’s recovery process. Cristina Grossi, co-lead with Sylvie, gave a ringing endorsement of EQIP’s impact, “This must be repeated across the province.”
CMHA Cochrane-Timiskaming: Impact of Recovery Plans (RP) on Client Recovery
- QI coach: Laura Daly-Trottier
- Data Coach: Alexandra Clement
Project Overview At CMHA Cochrane Timiskaming, they developed a documentation process called the Domain Oriented Recovery Record. When they were exploring their focus for a QI process, they knew they couldn’t tackle the entire documentation process, so they chose to focus in on the recovery plan (RP). They started by creating a run chart to look at the baseline data of how many clients have a recovery plan. They discovered that RPs were only in place for 55 percent of clients. They wanted to gain insights from both clients and staff. Clients with RPs were an important part of the process. A survey of 21 clients confirmed that RPs are very important to the client’s recovery process. In fact, 100 percent strongly agreed or agreed that their RP was helping them meet their goals. Clients said things like “Excellent guide!”, “RP helps my anxiety.” “My RP helps me focus.” When a tool like an RP can elicit these kinds of reactions from clients, CMHA Cochrane Timiskaming’s commitment ensuring clients have RPs grew even stronger. Their parallel process with staff, showed that staff had less confidence in the value and importance of the RP, with just over 60 percent of staff who agreed or strongly agreed that RPs helped clients meet their goals. CMHA CT used a number of QI tools including the 5 Whys, Fishbone and Pareto, and ultimately identified three root causes:
- Lack of communication in the organization regarding the rationale for a Recovery Plan
- Lack of organizational accountability in ensuring 90 percent of clients have a Recovery Plan
- Lack of staff completing recovery plans.
Their change ideas are focused on supporting staff to consistently complete RPs with each client, and have offered workshops. Their post-recovery plan workshop showed that 30% of staff were still struggling with specific aspects of completing the plan, so the QI team is adding individualized support to address that challenge. “The impact of this project has extended far and wide at this CMHA branch.” According to the Kathy King, QI Team Lead, “Our clients play a major role in the development of our change ideas.” The impact of this project has extended far and wide at this CMHA branch. In fact, Clark MacFarlane, the Executive Director, has starting using a QI lens in everything they do, including the little things. Omer Ducharme, the Executive Sponsor for the EQIP project, summed it up well, “We’ve always had a commitment to quality because we know the better we get, the better the services will be for our clients.” And that’s what it’s all about.
CMHA Sudbury Manitoulin: Hand Hygeine
- QI coach: Laura Daly-Trottier
- Data Coach: Alexandra Clement
Project Overview Proper hand hygiene is one of the most effective ways to reduce the spread of illness. At Canadian Mental Health Association Sudbury/Manitoulin, they recognized that there was an inconsistent approach to hand hygiene across their sites, and they weren’t able to measure compliance because self-audits weren’t completed consistently. They used run charts to look at the cold and flu rates among staff by quarter, and to look at compliance rates with the four moments of hand hygiene. They dug deeper into the challenge by using the Fishbone exercise to identify the root causes. They also used a Pareto Chart to explore the question, “How can we improve the hand hygiene process to be sure that all staff are participating in the self-audit and that we are monitoring the practice of healthy hand hygiene practices every day of the year?” Through these tools, a number of key root causes became clear, including the fact that hand hygiene compliance messaging was tied to accreditation, and not to staff health and safety. The self-audits were done infrequently, using a paper-based tool that was not user-friendly. To add to the inconsistency, staff didn’t see the value in completing the self-audits. Finally, being across four sites adds to the inconsistencies in approach – and there are no hand hygiene site champions. The team agreed to start by creating an online self-audit hand hygiene tool, which is being tested through a PDSA – Plan, Do, Study, Act – cycle. “We are already using the QI tools in other projects, and have reviewed and revised our QI plan in light of our new knowledge.” For Jessica Suban, “This is just a starting point. Even though the scope was narrow, the team gained a lot from their participation in the project. We are already using the QI tools in other projects, and have reviewed and revised our QI plan in light of our new knowledge.” Hand hygiene compliance is a common challenge in many organizations. The learnings from this project can inform and inspire others to tackle this issue as well.
CMHA Haliburton Kawartha Pine Ridge: Maximizing Social Enterprise Opportunities
- QI coach: Linda Saunders
- Data Coach: Nicole Adkin
Project Overview Catering Plus is an organization that creates employment for those with lived experience in the mental health system and/or barriers to employment. The funding provided by the LHIN does not cover all costs (including client wages) and the overall program has to be self-funded or revenue neutral. As a social enterprise, Catering Plus is quite distinct among the EQIP projects. With the risk of sustainability to the program, the EQIP QI support was a welcome contribution. They started by tracking down some key data points – food cost percentage, labour cost percentage and net sales chart. When those data points were put on a run chart, the large inconsistencies, challenges and opportunities became evident. A team comprised of caterers, the chef, the small business assistant, program manager, the improvement advisor and the data coach met and put the Root Cause Tool to use. They started with a process map that identified 19 pain points that required further analysis. They prioritized these using a “dotmocracy.” High labour costs was a top pain point they chose to explore further. As a root cause, they identified that some of the caterers struggled to start their shifts independently, resulting in longer shifts and inefficiencies. The group completed a Fishbone diagram, the 5 Whys process and a driver diagram to understand this better. After discovering a variety of possible reasons for this problem, the team used the Driver Diagram process to identify the following primary drivers of what the caterers needed to be able to start independently. These included: • They have all of the information that they need • They have confidence to start on their own • All groceries and supplies are available for the job • The workspace is clean and prepped Ultimately, they identified a number of change activities that led to 13 PDSA – Plan, Do, Study, Act – cycles. The focus was on how to lower food and labour costs to operate sustainably, better support and prepare the caterers in their role, and create efficiencies in operation. Change ideas explored included:
- Price changes to menu
- First cook position put in place, to increase efficiency and provide mentorship
- Scheduling calculator for predictable staff and food costs
- Food labelling/fridge journaling
- Updating “how-to” instruction sheets
- Sourcing different grocery stores, bulk buying and time of grocery shopping
“I now recognize the importance of taking the time to use the data.” For Sandy Woodhouse, the project lead, this process was incredibly insightful. As she says, “I now recognize the importance of taking the time to use the data. What we discovered was that there’s no magic bullet to solve the challenges, but there are things we can do – and the visual diagrams are helpful in identifying challenges and opportunities. Most importantly, we can never forget about the people side of change – this takes time and patience.” At Catering Plus, the opportunity to participate in and learn from the EQIP initiative may truly be the difference between being employed or unemployed for people in their region living with mental health challenges or barriers to employment. This is a powerful example of the life-changing impact that a focus on Quality Improvement can have on people’s lives.
CMHA Kenora: Increase Fluidity of the Assertive Community Treatment Team (ACTTT)
- QI Coach: Kim Elke
- Data Coach: Andrew Span
Project Overview The Assertive Community Treatment Team (ACTT) services see some of the most vulnerable people with mental illness, and support them to live in the community. CMHA Kenora Branch recognized that the flow-through of clients in their ACTT team was quite slow, and there was an assumption that they were keeping clients on the ACTT caseload longer than they needed to. This meant that the wait list for services is very long for others who need this high degree of support to live in the community. Through the Be Mind Full EQIP project, their aim was to increase the ACTT fluidity. At the diagnostic step, it became clear that the insurmountable root cause of the lack of fluidity was that there was a complete gap in services — there is no step-down service to transition clients to, and no psycho-geriatric outpatient services, and very limited services for anyone over the age of 55 with mental health issues. In retrospect, perhaps the team should have concluded this focus and project after the diagnostic phase when this insurmountable challenge was discovered. However, the team pushed forward, and there were some creative solutions that were identified, including creating a step-down service within CMHA’s existing ACTT. Despite the fact that they weren’t able to move through all the QI tools, the team and other colleagues at CMHA Kenora still learned a lot. Equally importantly, the ACTT team felt valued and appreciated by being included in the discussion and idea development for program changes. It was a good team building experience. “By working through the critical thinking, diagnostic tools and project charter for this work, the team has gained a better understanding and appreciation of the QI process.” “By working through the critical thinking, diagnostic tools and project charter for this work, the team has gained a better understanding and appreciation of the QI process,” explains Kim Elke, CMHA QI Coordinator and EQIP coach. “We’ll definitely be using these tool in other projects in the future.” CMHA Kenora’s project serves as an important reminder that not all projects are a huge success, but it’s important to learn from them and move forward. “There’s a lot of growth and innovation that happens with failure, and we’re making the most of that,” says Kim Elke.
How to Get Involved
Join our newsletter:
The best way to get up to date information on E-QIP is to join our mailing list where we send monthly updates on the project and upcoming events such as webinars and training sessions.
You can join our mailing list by clicking here.
Apply for QI Project Coaching:
You may see the range of projects that E-QIP has worked with over the first cohort of projects profiled here.
The Expression of Interest in Quality Improvement & Data Coaching Support is now open for Fall 2019! Applications accepted until October 11, 2019.
Become a member of the online E-QIP Community of Practice:
Join others in the sector by sharing QI expertise, tools and resources as we build a culture of QI across the province by becoming a member of E-QIP’s online CoP through Quorum. Quorum is Health Quality Ontario’s online space for collaborating with other healthcare providers that aer using quality improvement methods and tools to enhance healthcare services for Ontarians.
Become a member of the E-QIP CoP by clicking here.
Join or view a webinar
Check out the recordings of our latest webinars below. Subscribe to our newsletter to be notified of upcoming webinars.
The E-QIP Team includes core staff that supports the development and implementation of the project as well as QI and Data coaches that work closely with agencies to meet their quality improvement goals.
Debbie Bang, Co-Lead Excellence through Quality Improvement Project and Addictions and Mental Health Ontario
Debbie has worked in the addiction and mental health sector for over 30 years. She was a public health nurse and a mental health nurse working with youth in high schools. She developed a first of a kind consumer information centre in a Canadian Hospital and has been involved in qualitative and quantative research about health decision-making, cancer clusters, the impact of yoga with people with substance use issues and hearing from Canadians about the connection between mental health and an HIV diagnosis. Data and demonstrating value and outcomes has been a career long interest. During the last 18 years, Debbie has managed Womankind Addiction Service and Men’s Addiction Service Hamilton (MASH) at St. Joseph’s Healthcare Hamilton, project leading the amalgamation creating Womankind, the transfer and expansion of MASH from one hospital to another, managing the Eating Disorder program and was the management chair of the health and safety committee. Her credentials include a degree in nursing, graduate degree in Health Promotion, a number of leadership and management diplomas and a green belt in LEAN. Debbie holds faculty appointments at McMaster University in the School of Nursing and Department of Psychiatry and Behavioural Neurosciences, teaches motivational interviewing and trauma-informed care. Her interest in quality improvement is long standing and Debbie learned early the value of data to provide perspective on how services are being delivered and what tweaks/ changes are needed to improve the quality of the services provide to the people we serve.
Debbie is the Director of Quality Improvement with Addictions and Mental Health Ontario (seconded from St. Joseph’s) and is co-leading the Excellence through Quality Improvement Project (E-QIP) with Michael Dunn. For Debbie, this is a very exciting time for the addiction and mental health sector. The work of the Mental Health and Addiction Council, the Mental Health Commission and the commitment by the provincial government highlight both the need for and the value of community addiction and mental health services. E-QIP provides the sector with the opportunity to use a systematic approach to improving the quality of the services that are available for Ontarians. Part of the intent of E-QIP is to build both quality improvement capacity and capability and to share the good news stories and accomplishments so others can benefit from the learnings. These emerging stories are inspiring and allow us, the sector, to speak confidently about the work we do each day with clients and the differences that are made using a quality improvement lens and meaningful data measurements.
Ashley Koster, Program Manager, Excellence through Quality Improvement Project, Canadian Mental Health Association, Ontario
Ashley joined the E-QIP team in December 2018 as Program Coordinator where she supported the team in several key functions including administrative support, financial management, event coordination and booking travel. During the year and a half she has been with the team, Ashley has developed a keen interest in Quality Improvement and has gained valuable QI knowledge including the Model for Improvement, diagnostic tools and developing and testing change ideas. Ashley is thrilled to advance her career with the E-QIP Team as Program Manager and looks forward to assisting agencies in the mental health and addiction sector move their own “QI bar” during the next phase of E-QIP! Ashley graduated from the University of Guelph with an honours degree in psychology and holds a certificate in human resources management from George Brown College. She is currently pursuing her project management professional (PMP) certification. Ashley currently lives in downtown Toronto with her wife and two dogs, Darwin and Homer. In her free time she enjoys cooking, travelling and spending quality time with friends and family.
Amy Patel, Program Manager, Excellence through Quality Improvement Project, Addictions and Mental Health Ontario
Amy is a Program Manager for the Excellence through Quality Improvement Project (E-QIP), seconded from the Canadian Mental Health Association, Ontario, and joined the team in July 2019 with a keen interest in the mental health and addiction sector. She volunteers as a Crisis Responder for Kids Help Phone and has over 5 years of experience in the public health and hospital sector, managing research and evaluation projects for a number of health organizations including St. Michael’s Hospital and the Provincial Council for Maternal and Child Health at the Hospital for Sick Children.
Amy holds an Honours Bachelors of Science in Science and Business, Biology Specialization from the University of Waterloo and a Masters of Science in Health and Rehabilitation Sciences from Western University. She also has a Lean Six Sigma Yellow Belt and is pursuing her Project Management Professional (PMP) certification.
As a Program Manager for E-QIP, Amy is looking forward to further developing her knowledge in quality improvement and change management within the mental health and addiction sector.
Alexandra Clement, QI Coach, Excellence through Quality Improvement Project
Alexandra Clement supports the Excellence through Quality Improvement Project (E-QIP) as a Quality Improvement Coach. Alex is currently seconded from the Child and Family Centre (Sudbury) where she works as a Knowledge Specialist focusing on the agency’s quality improvement, quality assurance, and training portfolios. Since moving to Sudbury in 2007 she has graduated from Laurentian University twice (B.Sc. and M.A.) and has started her career in the mental health and addictions sector. Previously, Alex has supported quality improvement initiatives in the child and youth, as well as adult, mental health sectors as a Data Coach (E-QIP) and Research Analyst.
Outside of work, Alex endeavours to give back to her community through volunteering with local organizations and is hopeful that she can contribute to the wellbeing of community members through advocacy and social action.
Laura Daly-Trottier, QI Coach, Excellence through Quality Improvement Project
Laura Daly-Trottier, seconded from CMHA Nipissing Regional Branch, in the North East LHIN, delivers Quality Improvement Coaching through Excellence through Quality Improvement Project (E-QIP). Since October 2016 Laura has delivered Quality Improvement Coaching to member organizations in the Mental Health and Addictions sector throughout the province of Ontario in an effort to increase the capacity for Quality Improvement. Laura knows firsthand the importance of using a structured approach to Quality Improvement as well as recognizing that each initiative is unique with its own set of values and purpose. Prior to working with E-QIP, Laura Daly-Trottier worked as a Quality Coordinator at CMHA Nipissing where her focus was to ensure that service standards were met as well as overseeing the development and maintenance of the agencies quality assurance and improvement systems, including the continual monitoring of the agency’s client data management system. Laura was responsible for coordinating and implementing staff orientation and training events and was a contributing member of the Governing Health and Safety Committee. She is also trained facilitator for The Living Life to the Full program at CMHA Nipissing. Laura served on the NE LHIN Implementation Team in 2016 for the Ontario Perception of Care Tool acting as the Agency Lead at CMHA Nipissing. Laura thoroughly enjoys providing coaching supports through the offerings of E-QIP and is passionate about improving care in a meaningful way for service recipients, friends, families and service providers.
Abel Gebreyesus, Data Coach, Excellence through Quality Improvement Project
Abel Gebreyesus is a Data Coach for the Excellence through Quality Improvement Project (E-QIP) since the project’s first phase in October 2016. He worked with many mental health and community based organizations in coaching and facilitating their data needs related with the project. Additionally, he is also Data Management Coordinator (DMC) at TAIBU Community Health Centre since 2009; and was also involved from 2009 – 2011 at LAMP Community Health Centre; and from 2011-2013 in Flemingdon Health Centre – both in a DMC position.
Other than in CHC sector, Abel was also involved in Family Health Team (FHT) sector; and worked for four Peel Region FHTs as Quality Improvement Decision Support Specialist (QIDSS) in 2013-2016.
Abel also involved at different capacities, such as Project Manager for Nightingale on Demand Transition Project and Coordinator for Business Intelligence Reporting Tool coordinator in those organizations mentioned above. He also worked briefly for Cancer Care Ontario (CCO) as a Business Analyst. For many years, Abel contributed in different teams involving data, quality improvement, reporting and business Intelligence (BI) areas.
Abel holds a Masters of Health Informatics (MHI) from Dalhousie University; and he is Certified Lean Six Sigma Green Belt (CLSSGB) professional.
Linda Saunders, Data Coach, Excellence through Quality Improvement Project
Linda Saunders is seconded part-time from the Canadian Mental Health Association, Haliburton, Kawartha, Pine Ridge Branch (CMHA HKPR) in the Central East LHIN.
Linda supports the Excellence through Quality Improvement Project (E-QIP) as a Quality Improvement (QI) Coach. Since its inception Linda has supported many mental health and addiction organizations in Ontario with their quality improvement projects in an effort to improve the quality of services offered to clients and families.
In addition to her work with EQIP, Linda is also the Director of Corporate Services for CMHA HKPR and she also worked in a similar role at a children’s mental health centre in Windsor. For more than thirty years, Linda has gained experience in both the public and private sectors. She is responsible for the human resources, financial, property, information technology, administration, privacy, community engagement, and quality improvement systems of the Canadian Mental Health Association. She works closely with all programs within CMAH HKPR to integrate key principles that ensure the delivery of safe, effective and efficient care and services to the community while maintaining a culture of continuous quality improvement. She is also an active member in her community.
Linda thoroughly enjoys her work providing quality improvement supports to mental health and addiction organizations in the province as they work towards strengthening the sector in quality improvement and supports to clients.