Sample Improvement Goals

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The ideal SFH ACTION project goals would be evidence-based, measurable, can be completed within a 10-month timeframe, and align with organizational priorities. Please note that teams may revise their project goals after the first learning event prior to completing the project charter.



  • Increase rate of baseline CAM screening from 75% to 90% on unit A for patients age 65 and older

  • Implement preventative strategies for all patients at risk of delirium on two hospital units 

  • Implement management strategies (order sets, care strategies) for patients screening positive for delirium on medical unit

  • Implement CAM assessment on electronic chart to track rate of baseline delirium screening and incidence

  • Develop/implement mechanism to engage patient/family in delirium prevention/management on medical unit

  • Pilot early mobility initiative to reduce functional decline on one hospital unit

  • Implement a night-time quiet program (e.g. reduce use of pagers and overhead announcements) to improve sleep of patients on two hospital units

  • Conduct physical environment audit on 3 patient units to support delirium prevention, and implement at least 3 recommendations from the audit

  • Implement a protocol to identify appropriate power of attorney/substitute decision maker for all patients on unit A

  • Implement the Nutrition Risk Screening Tool on unit A in patients age 65 and older to prevent malnutrition

  • Reduce unnecessary use of foley catheters by 10%

The Ontario Senior Friendly Hospital framework provides an evidence based blueprint to guide hospital-wide improvements in services for frail seniors. For more information, please visit