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Continuous Quality Improvement Initiative Report
March 2023

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 volunteer, 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.


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

  • resident, 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.



Priority Indicator #1: To maintain the percentage of potentially avoidable emergency department visits for LTC residents to under 5%.

The Leamington Mennonite Home has been successful in decreasing the percentage of potentially avoidable ED visits from 10% to 0%. Our goal for 2022-2023 is to maintain this current level.

The Home plans to continue to focus on our palliative care program to ensure there are limited unnecessary visits to ED when it would be more beneficial to the resident to stay at the home for comfort care when they wish to do so.

Priority Indicator #2: Decrease the percentage of LTC residents not living with psychosis who were given antipsychotic medications from 21.3% to 19%.

Decreasing antipsychotic use continues to remain a priority for the Leamington Mennonite Home. Our current average is at 21.3%, which is only slightly lower than the provincial average of 22%, the Home would like to continue to improve in this area and has set a goal of 19%. We recognize the importance of medication safety, and we feel it is very important for resident’s to be receiving only appropriate medications and this includes antipsychotics.

Priority Indicator #3: Maintain the percentage of positive responses to “I can express my opinion without fear of consequences” at 100%.

Resident safety and comfort remain an important priority. Through staff education we have been able to increase positive responses to this question from 90.7% to 100%. We will continue to work to ensure this number is maintained.

Priority Indicator #4: Increase the percentage of positive responses to “What number would you rate how well the staff listen to you” from 59% to 95%.

Increasing positive responses. from 59% to 95%. to this question 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 #5 Maintain the percentage of positive responses to “Would you recommend this nursing home to others” at 96%

General and overall satisfaction the residents’ and their families have with their experience at the Leamington Mennonite Home is very important to us. The Home’s goal will continue to seek opportunities for improvement based on feedback and recommendations from our residents and their families. We will continue to encourage feedback and would like to hear more from the residents and families on their ideas for quality improvement initiatives. We are also striving for increased participating in the satisfaction survey to ensure we are receiving the best sample of responses from the residents.

Priority Indicator #6 Decrease the percentage of residents who fell from 18.9% to 16%

The Leamington Mennonite Home has identified that the Percentage of resident that have fallen has increased slightly, from 16.7% to 18.9%. Our goal is 16%, to be below the provincial average. The fall committee meets monthly to evaluate all falls, determine cause, and try to establish interventions to prevent further falls from occurring.

The Leamington Mennonite Home is currently reviewing 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.

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