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Quality Improvement Plan 2013/2014

2013/14 Quality Improvement Plan
for Primary Care organizations in Ontario

Overview of Our Organization’s Quality Improvement Plan

This section should highlight the main points of your organization’s QIP and describe how it aligns overall with other planning processes within your organization and more broadly with other initiatives underway across the province. 


[In completing this overview section of your organization’s QIP, you may wish to consider including the following information:


Overview[Provide a brief overview of your organization’s QIP]:


North York Family Health Team (NYFHT) Quality Improvement (QI) activities are well aligned with our organizational vision, mission and value. We strive to provide high quality care to the patients in our community. The domains of access, integration, patient-centeredness and effectiveness are all cornerstones of quality. We are committed to achieving the targets that we set for our organization.


As part of its commitment, NYFHT has actively supported its staff, physicians and their office staff in QI training. The leadership team and the Information Technology / Information Management Committee are involved in quality spread and sustainability initiatives, and have embraced a culture of quality and promoted collaboration among clinicians and staff.


Focus[Describe the objectives of your organization’s QIP and how they will improve the quality of care in your organization]:


Our QI Plan will help to ensure that all our QI activities are structured, integrated, reviewed and monitored for progress across all our sites.


The NYFHT QI Plan for 2013-14 will focus on four quality dimensions: access; integration; patient centeredness; and effectiveness.


  1. Access: we will conduct a patient experience survey at the offices of our 65 physicians. Using the results of the survey, we will prioritize and focus on those physician practices that need attention first, specifically those physicians whose patients wait greater than 5 days on average. For those practices, we will then formally calculate third next available appointment and perform supply-demand analysis. In future years, we will be able to work with these physician offices to create strategies for improvement. The goal of this dimension is to identify gaps in access to care, as defined by the Ministry of Health.


  1. Integration: We will increase the post discharge visits from 28% to 35 % by engagement and education of team regarding the importance of and mechanism for timely follow-up in these patient groups. We will define new workflow for discharge summaries in each physician office. The goal of this measure is to identify ways to increase the post-discharge primary care visit within seven days.


  1. Patient Centeredness: We will implement a patient experience survey. We plan to receive 10 completed surveys per physician by distributing 20 questionnaires in each of 66 physician practices. The goal of the survey will be to obtain patients’ feedback related to care provided and the extent to which they are involved in making decisions about their own care.  


  1. Effectiveness (Cancer screening): We will report effectiveness measures related to breast, cervical and colorectal cancer screening as they are a provincial priority. In the past year, we were able to increase the rate of cancer screening for all three areas (mammogram 84%, Pap smear 92 %, FOBT 70 %) by identifying unscreened patients in our EMR. We reached out to these patients by reminder letters and telephone calls. We plan to sustain the rate of screening above 80% for breast and cervix, and to increase the rate of screening for colorectal cancer to at least 80%.



We use our EMRs to track data over time for FHT-wide QI and research activities; to identify patients who are due for preventive visits and evidence-based screening; and to define which patients require outreach.  Our team has been active in standardizing care using EMR templates and consistent data entry. 


Our EMRs facilitate patient safety and quality improvement through use of system reminders, alerts, and predictive tools. Embedded clinical guidelines promote standardized, evidence-based practices. Electronic prescribing and test-ordering reduce errors and redundancy.


NYFHT has formed an Information Management-Information Technology (IM-IT) Committee that has representation from every physician group, senior management, allied health professions and the family medicine residents. In the past four years, the IM-IT committee has served to create and support data entry initiatives and to standardize EMR templates.


Additionally, at NYFHT we are involved in the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). This is Canada's first multi-disease electronic record surveillance system. It is a library of digital health information of patients with chronic disease. Collected data allow production of reports for physicians about their practice and allow comparison to others within the region, province, and across the country. 


CPCSSN developed a “Data Presentation Tool” (DPT) software application. This tool enables the production of quality reports using cleaned and standardized data extracted and merged from EMRs. This then allows for informed decisions based on actual primary care data. Tools such as the DPT can overcome the limitations of current EMRs and help physicians transform their data into useful information. NYFHT is the implementation site for the DPT. We therefore draw on this data to augment our EMR data, especially where EMR searches are limited in quality.



1. Partnering with our external stakeholders on a shared vision and accountability is essential to improving transitions of care. One of the areas of focus will be to improve recognition of meaningful hospital communication such as discharge summaries and creating new workflows within our FHT to follow receipt of these documents. The goal is to increase primary care visits within 7 days of hospital discharge.

2. Potential implementation of Health Links will ensure that high-user patients who need care receive the right care at the time in the right location, which is likely in the community. We are developing additional clinical efforts to be able to form a “Post-Discharge Team” within our FHT as our major contribution to Health Links. This team of allied health professionals will assist in timely patient contact after hospital discharge.



We will continue to collect chronic disease registries, cancer screening and vaccination data through our EMRs and through DPT, for reflection and planning purposes.



We will form a new QI Committee, which will augment the work of our IM-IT Committee. The QI Committee will


The North York Family Health Team faces a number of risks and challenges that may affect accomplishment of the QI Plan:


Our Improvement Targets and Initiatives


Purpose of this section:  Please complete the “QIP template” (Excel file). Please remember to include the spreadsheet (Excel file) as part of the QIP package for submission to HQO (



Attachment (click to download):
 Adobe Acrobat Document Quality Improvement Plan.pdf