Concerned about the number of inspections for Critical Incidents and Complaints at your LTC Home?

As an Executive Director, or as Chairman of the Board, or Coordinator for Continuous Quality Improvement, or a member of the Quality Committee, or just a staff member with the good of our residents at heart - am I concerned with the number of Ministry of Health and Long-Term Care (MOHLTC ) inspections for complaintsand critical incidents? If this is an area for concern then one or more of three things is probably not happening as well as they should:

Firstly: Are we measuring all the right things? Of course, we are measuring for CIHI and HQO and our own Board meetings, but have we got the metrics in place to red flag the likelihood of an avoidable critical incident occurring, to red flag the future likelihood of one or more resident complaints that could trigger an inspection? In the field of quality management we call this type of metric KPIs, Key Performance Indicators. KPIs are the organization’s "vital signs", the vital few metrics that report on the health of the organization in living out its mandate from and to society. KPIs should not be confused with the kind of quality indicators that are reported to HQO such as falls, wounds and restraints, although KPIs might well incorporate some of those metrics.

Secondly: Are we monitoring effectively? Assuming that we actually do measure those KPIs, are we reporting them in an accountable manner to the right people who are best positioned to effect change – change in our processes and change in our culture? Managers and others in positions of responsibility who are not being fed the information they need to do their job need to report this as a concern up the management chain. Without KPIs you are flying blind.

Thirdly: Are we managing efficiently and effectively? Assuming that we are reliably measuring and monitoring KPIs, are the process owners and managers sufficiently trained, mandated, empowered, resourced and accountable to take the actions necessary to enhance the Quality Management System (QMS) and foster a culture of quality to prevent the bad stuff happening? If not, that is fodder for a KPI in itself and needs to be reported as a resourcing issue to senior management. Managers and others in positions of responsibility who feel they need training need to do whatever it takes to get it; if your department is at risk for non-compliance because you are lacking resources then that needs to be reported, repeatedly if necessary.

What do you think? Let's have a discussion.