Let’s celebrate the successes of the DQIEPE

Joanne Côté, Director of Quality, Innovation, Evaluation, Performance and Clinical Ethics for CIUSSS West-Central Montreal, accepts the Innovation team’s certificate from Dr. Lawrence Rosenberg (centre), President and CEO of the CIUSSS, and John Whelton, Vice-President of Operations of the Leading Edge Group.
Joanne Côté, Director of Quality, Innovation, Evaluation, Performance and Clinical Ethics for CIUSSS West-Central Montreal, accepts the Innovation team’s certificate from Dr. Lawrence Rosenberg (centre), President and CEO of the CIUSSS, and John Whelton, Vice-President of Operations of the Leading Edge Group.

With its solid and varied expertise, the Directorate of Quality, Innovation, Evaluation, Performance and Clinical Ethics supports clinical and administrative departments from a strategic, tactical and operational perspective. While leadership of the directorate is now under Joanne Côté, its previous leader, Anne Lemay, deserves to be acknowledged and warmly thanked for her significant contribution to most of the successes in this publication.

Information Exploitation and Performance Evaluation Team

  • Creation and dissemination of a portal offering reports and dashboards produced by the team using Microsoft tools: http://jgh000195vmim/Reports_PRODDB1/browse/ 
  • Deployment of the Med-GPS software at the JGH and the former CSSS facilities. This software allows management to assess the performance of its business area in real time, in general or in detail. Links are now in place to align the activities of the JGH, the CLSCs and the two rehabilitation hospitals.
  • Participation, as project manager, in the CPSS project (cost per care and service pathway). Since 2018, this project has been progressing according to schedule and deliverables.
  • Implementation of a file loan system at the Constance-Lethbridge site. Approximately 72,000 records have been transferred from the old Access database to a multi-site database.
  • Computerization of the process for production of medication circuit incident / accident indicators for the CIUSSS facilities. The tool is used to facilitate the validation and reporting of data from the healthcare and service safety information system (HSSIS).
  • Application developed to monitor Carbapenemase Producing Enterobacteriaceae (CPE) infections, presented to the CHU de Québec and the Direction de la santé publique. The CHU de Québec will use it as a model to create a similar application. During an episode of Découverte, a Radio-Canada TV program, this application was mentioned. 
  • Production of periodic reports to measure the volume of interventions performed in the operating room, such as the cost of supplies consumed and other expenses, including salaries.
  • A process for collecting, validating and using CIUSSS statistical information was presented to the Audit Committee of the Board of Directors.

Innovation Team

Created in 2015, the team is proud of its progress and achievements:

  • Supporting clinical teams in developing nine integrated practice units (IPUs) and care and service trajectories:
    • Cardiovascular (trajectory of acute coronary syndrome)
    • Neuroscience (stroke trajectory)
    • Musculoskeletal (hip fracture)
    • Chronic pain
    • Local services
    • Geriatric profile
    • Mental health, 12 to 25 years old
    • Children below the age of 7 with overall developmental delay
    • Mother-Child-Family (perinatal mental health)

A reference framework and toolbox have been developed and made available to all. The team also presented and disseminated its work model to the HEC Montréal Pôle santé, the Communauté de pratique en amélioration continue (CvPAC) and the Canadian Home Care Association (CHCA).

  • Support by the team for two major projects, with a broad scope affecting multiple areas: reengineering the recruitment and staffing process of the Human Resources Team, and the suitability process for research projects of the Academic Affairs Team.
  • Deployment of a culture of continuous improvement (Lean), with a view to organizational consistency and respect for the CIUSSS’s vision. The team supported three directorates in 2018-2019. As a result, the Directorates of Mental Health and Addiction, SAPA (home care), and Frontline Integrated Services, as well as the Innovation team, were able to earn Gold Level certification. Our CIUSSS has just become the world’s first healthcare network to be certified by the Leading Edge Group, which officially recognizes companies and organizations that implement the globally accepted concepts of Lean management.
  • Accompaniment of clinical teams during patients’ or residents’ relocation, in a rigorous and supervised manner. Since 2014, 12 moves have been carried out safely and without incident for users and employees. In 2019, the team contributed to the move of JGH residents to the Henri Bradet Residential Centre and the relocation of half of the patients from Catherine Booth Hospital to the JGH.

Quality Team

The Quality, Continuous Improvement, Risk Management and Patient Experience team has several successes to its credit:

  • Contributing to developing the Mission and Values Statement, the Code of Ethics and the ethical framework for the CIUSSS. The team ensures that these guides and the True North are at the centre of decisions, in order to ensure consistency.
  • Since September 2018, implementation of the Planetree approach to person-centred care and services, in partnership with DRHCAJ and all directorates. The launch of this approach was made in the presence of representatives from Planetree International and 200 leaders of our CIUSSS. More than 400 ambassadors were trained in March 2019. Their self-assessment, carried out in autumn 2019, will make it possible to identify areas for improvement and to implement action plans to meet and maintain best practices.
  • Support for a safety culture and quality reporting. The team is actively involved in event management and it celebrates maintaining and improving reporting rates to the CIUSSS:
    • Management of 16,000 accident and incident reports related to sentinel events (AH 223) in 2018-2019
    • Review of 60 sentinel events, with implementation of improvement plans
    • Quarterly reports to clinical teams: risk management, reporting rates, event types, severity and follow-up of improvement plans
    • Quarterly reports to Continuous Quality Improvement (CQI) committees: events related to organizational practices required to track improvements
    • Training in event reporting and disclosure
    • Planning and running security and activity weeks at several CIUSSS facilities, including a day of kiosks on quality initiatives and results
  • Support for measuring and improving the user experience: preparation and administration of user experience measurement questionnaires (HCAPHS- CPES) across all CIUSS directorates, reports to management and teams, and improvement plans.
  • Deployment of a Patient Partner Program: recruitment and integration of 45 patient partners into CQI teams or key committees or initiatives with program evaluation and improvements.
  • Celebration of accreditation visits:
    • 2018: 99.6% result related to quality management, safety, user experience and partnership
    • June 2019: 97.6% result related to stroke standards of distinction in rehabilitation
    • November 2019: 99.1% result for the Direction régionale de santé publique of Montreal
  • New responsibilities, since April 2019, for certification of the 30 residences for the elderly in our area.

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