Continuous Quality Improvement Initiative Report
March 2025

The Quality Improvement Initiative Plan of the Leamington Mennonite Home remains the cornerstone to the care, support, and quality of resident life.  Our QIP Program continues to support the Mission Statement of the Leamington Mennonite Home which identifies that:

Past legacy binds our commitment to compassionate care. Through faith-based values, we strive for excellence, accountability, and uniqueness in respect to the best care and well-being of each life we touch.

The designated Lead for the Continuous Quality Improvement Initiative is Melissa Laforce-Ostrander, RN MDS-RAI Coordinator.

QIP PLANNING CYCLE AND PRIORITY SETTING PROCESS 

The Leamington Mennonite Home has developed Quality Improvement Plans (QIP) as part of our annual planning cycle. The Home’s planning cycle includes an evaluation of the following factors to identify preliminary priorities: 

• ongoing analysis of performance data over time available from the Canadian Institute for Health Information (CIHI); with areas indicating a decline in performance over time and/or where benchmarking against self-identified peer organizations suggests improvement required.

• residents, family, and staff experience survey results.

• emergent issues identified internally (trends in critical incidents) and/or externally. 

• input from residents, families, staff, leaders, and external partners, including the MOLTC.

• mandated provincial improvement priorities (e.g., HQO). Preliminary priorities are subsequently presented and discussed at various forums to validate priorities and identify additional priorities that may have been missed. These forums include the leadership team, Resident Council, Family Council. 

QUALITY INDICATOR PRIORITIES FOR 2025/26

Priority Indicator #1: Percentage of all staff who have completed relevant equity, diversity, inclusion, and anti-racism education. We achieved our goal of having all Leadership and Registered Staff complete equity, diversity, inclusion, and anti-racism education. This year we will continue to provide this education to all staff Advancing equity, inclusion and diversity and addressing racism to reduce disparities in outcomes for residents, families, and providers is the foundation of a high-quality health system.

Priority Indicator #2: Increase the percentage of positive responses to “I can express my opinion without fear of consequences” to 100%. Resident safety and comfort remain an important priority. Our current performance is not ideal at 66.67%. We have launched a new learning platform, which we will use to provide education to all staff. 

Priority Indicator #3: Increase the percentage of positive responses to “What number would you rate how well the staff listen to you” from 41% to 85%. This indicator remains a priority for the Leamington Mennonite Home. The Quality Improvement Committee will continue to work with staff to learn the art of active listening.

Priority Indicator #4: Hand hygiene compliance among health care providers. Our IPAC Lead has introduced new auditing software, which allows our Registered Staff to perform frequent hand washing audits. We are also providing education on the 4 moments of hand hygiene. We are currently at 88% compliance and will work towards 100%.

Other Continuous Quality Improvement Initiatives

This year we are implementing the RNAO Clinical Pathways for Long-Term Care Homes. The RNAO Clinical Pathways are evidence-based, standardized tools, derived from RNAO's Best Practice Guidelines (BPGs), designed to enhance staff capacity, optimize resident care and outcomes, and support legislative and regulatory compliance in long-term care settings.

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• Based on RNAO's Best Practice Guidelines (BPGs):

  • RNAO Clinical Pathways are built upon the foundation of RNAO's internationally recognized BPGs, which are evidence-based and designed to promote best practices in nursing care. 

• Contextualized for Long-Term Care:

  • These pathways are specifically tailored for the long-term care (LTC) sector, ensuring they are relevant and applicable to the unique needs of residents and staff in these settings. 

• Enhance Staff Capacity:

  • RNAO Clinical Pathways are designed to empower staff, especially novice and agency nurses, by providing a structured approach to care, reducing errors, and supporting clinical decision-making. 

• Promote Resident-Centered Care:

  • By providing a standardized approach to care, these pathways help ensure that residents receive consistent, high-quality care that is focused on their individual needs and preferences. 

• Improve Staff Efficiency:

  • The pathways streamline workflows and reduce orientation time, allowing staff to focus on direct patient care and improve overall efficiency. 

• Support Legislative and Regulatory Compliance:

  • RNAO Clinical Pathways are designed to help LTC homes meet legislative and regulatory requirements, ensuring they provide safe and effective care. 

• Available for Specific BPGs:

  • RNAO Clinical Pathways are currently available for the following RNAO Best Practice Guidelines: Person- and Family- Centered Care, Preventing Falls and Reducing Injury from Falls, Assessment and Management of Pain, Delirium, Dementia, and Depression in Older Adults, Assessment and Management of Pressure Injuries, A Proactive Approach to Bladder and Bowel Management, and A Palliative Approach to Care in the Last 12 Months of Life. 

• Delivered through Nursing Advantage Canada:

  • RNAO Clinical Pathways are delivered through PointClickCare's Nursing Advantage Canada platform, a digital solution for electronic medical record systems in long-term care. 

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The Leamington Mennonite Home continues to review all the Home’s policies, procedures, and protocols for the Continuous Quality Improvement Initiative, as well as the process used to identify our priority areas for quality improvement and the processes to monitor and measure progress, identify, and implement adjustments and communicate outcomes for the Home’s priority areas for quality improvement.

This is a living document, which will change and evolve over time, Check back periodically for updates.