Quality Improvement Plan 2012-13

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Overview of Our Hospital’s Quality Improvement Plan

The Middlesex Hospital Alliance has embraced the legislative requirements of Excellent Care For All Act June 2010 to advance quality improvement plans at all levels throughout the two hospital sites. Both Four Counties Health Services and Strathroy Middlesex General Hospital have established corporate, hospital specific and departmental indicators. Quality improvements targets have been achieved through the formal provincial Quality Improvement Plan process, public reporting indicators, numerous internal LEAN initiatives and collaboration with regional hospital and community partners.

Achievements include

  • Greater than 33% improvement in hand hygiene compliance before patient contact
  • Greater than 40% improvement in hand hygiene compliance after patient contact
  • Achievement of ALC % of patient days target of less than or equal to 15.7 at 9.6
  • Established and developed an informed, knowledgeable Quality Committee of the Board
  • Established Critical Incident and Disclosure of Harm Policy and Procedure inclusive of timely report to the Board guidance
  • Achievement of balanced or better Financial Total Margin

  • Procurement and selection process of Staff and Physician Survey to assess satisfaction and provision of quality care
  • Public consultation of existing Patient Right and Responsibilities to affirm its representation as

The MHA Patient Declaration of Values

The MHA Quality Improvement Plan 2012-2013 builds upon the improvements achieved during the course of the previous year by selecting some of the same targets and initiatives to strive for greater improvements. The MHA has also selected additional quality improvements from recommended indicators, and local community based improvement interests as guided by the MHA Strategic Plan and the Southwest LHIN Report on Performance. And the MHA is doing so with greater involvement of all stakeholders and the MHA Board of Directors, as informed by the Quality Committee of the Board.

Quality Improvement Plan Targets and Initiatives include:

  • Hand Hygiene Compliance Before and After Patient Contact: Improved compliance and demonstrated sustainability over previous year’s achievement, through enhanced electronic audit process, greater audit frequency, volume and departmental display of achievements.
  • C. Difficile: Sustain or reduce excellent low frequency of incidence through continued surveillance and review of antibiotic stewardship improvement maps
  • Ventilator Associated Pneumonia (VAP): Sustain zero incidence of VAP in community hospital ICU setting.
  • Central Line Associated Bloodstream Infection: (CLI): Sustain Zero incidence of CLI in community hospital ICU setting.
  • NEW!!! Surgical Safety Checklist (SSCL): Completion at a rate of greater than or equal to 97% of all three phases of the SSCL to eliminate as many possible risks before and during surgical intervention.
  • Total Margin sustain zero or better balance of institutional financial health.
  • ED Wait Times Admitted Patient Length of Stay: Build upon current improvement initiatives addressing several key processes which impact upon the time to admission to inpatient unit. With continued dissemination of new process improvements, reinforcement of clinical expectations, the abilities of the team and celebration of performance achievements, this target will continue to demonstrate currently improving wait time results.
  • Urgent Hip Fracture time to surgical repair within 48 hours of patient registration NEW!!!: MHA, in collaboration within our two hospitals and the MHA participation with the SW LHIN regional urgent hip fracture orthopedic partner hospitals will meet the clinical best practice of time to surgery within 48 hours.
  • CT Wait Times NEW!!!: Sustain and reduce current performance in CT wait times
  • Diabetes Education Center (DEC) NEW!!!: sustain and reduce current wait time access to appointments with Diabetes Education clinical expertise
  • Patient Centered: Patient Satisfaction of Overall Quality of Care
  • Patient Experience NEW!!!: Percentage of patient complaints which are responded to within 2 business days
  • Patient Centered: Staff and Physician Satisfaction and Quality Care Survey response target. NEW!!!
  • Percentage of ALC Days Sustain and reduce current percentage of ALC days in collaboration with physician and community support partners and early identification of discharge plans.

The Link to Performance-based Compensation of Our Executives

The MHA Executive compensation, including the percentage of salary at risk and targets that the executive team is accountable for achieving is linked to performance in the following way: 

Performance- based Compensation as a Percentage

of Annual Salary


CEO Compensation  Senior Management Compensation 
Total variable pay linked to achieving QIP targets 







The performance allocation plan below is used to determine the magnitude of the allocation:Quality


Objective CurrentPerformance

Target* Weighting 100% 66% 33% 0%
Safety  Improve Provider Hand Hygiene compliance before and after patient contact 
















Effectiveness  Sustain Organization Total Margin Financial Health 














(- 0.51)-(-1.00)





Access  Improve ED 90 

th %ile Admitted Wait Time Hours















Patient-Centered  NRC Picker: Overall Care Provided 
















Integrated  Reduce ALC patient days 




≤ 14.5 




≤ 14.5 


14.6 – 15.8 


15.9 – 17.0