Continuous Quality Improvement Initiative Report
March 2026

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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:

“The Leamington Mennonite Home is a faith-based community of care,

providing compassionate and comprehensive Long-Term Care, responsive to the

individual needs of residents through a team effort, consisting of a multidisciplinary team of staff and family members, together with volunteers, Church, and community

resources, which place residents first in our circle of care and support”

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. 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 2026/27

Priority Indicator #1: Rate of ED visits for modified list of ambulatory care–sensitive conditions* per 100 long-term care residents.

• 29% of Emergency department visits in the last calendar year were due to falls. We will work on Priority Indicator # 5 to reduce the number of falls. Our performance on both these indicators remains better than the provincial average.

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 66.66%. We will continue to provide education to all staff.

Priority Indicator #3: Maintain the percentage of positive responses to “What number would you rate how well the staff listen to you” at 100%

• 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: Decrease the percentage of long-term care residents whose stage 2 to 4 pressure ulcer worsened from 5.4% to 2%.

• We will implement more proactive wound care practices, rather than reactive. We will provide education to staff on early detection and management of skin breakdown.

Priority Indicator #5: Percentage of LTC home residents who fell in the 30 days leading up to their assessment.

• We continue to purchase more electric beds and other fall prevention tools. This may not prevent falling, but we can decrease the risk of injury.

Priority Indicator #6: Decrease the percentage of LTC residents without psychosis who were given antipsychotic medication in the 7 days preceding their resident assessment from 17.86% to 15%.

• The home Physician and Pharmacist continue to address this indicator with quarterly medication reviews.   We remain below the provincial average on this indicator.

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.