Continuous Quality Improvement Initiative Report
March 2024

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:

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“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.”

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

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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

• 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.

QUALITY INDICATOR PRIORITIES FOR 2024/25

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Priority Indicator #1: Percentage of Leadership and Registered Staff who have completed relevant equity, diversity, inclusion, and anti-racism education.

A new indicator for this year. Advancing equity, inclusion, and diversity and addressing racism to reduce the disparities in outcome for residents, families, and providers is the foundation of a high-quality health system.

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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 79%. We are in the process of obtaining a new learning platform for staff education, to provide the best education in customer service for our staff.

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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.

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Priority Indicator #4: Hand hygiene compliance among health care providers.

We have chosen to include an indicator that will engage our Infection Prevention and Control Program. We have purchased auditing software to assist our IPAC lead in tabulating data on our compliance rate. We hope to achieve 100% compliance.

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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.

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