balanced scorecard technical specification

Report on Performance Scorecard Technical Specification

South West LHIN

August 20, 2014

This document contains technical guidelines for how each indictor on the Report on Performance Scorecard is produced. For any questions about this document, please email [email protected] with ‘ROP’ in the subject line.

mailto:[email protected]

2 South West LHIN Balanced Scorecard Technical Specifications

Report on Performance Scorecard: Technical Specifications

TABLE OF CONTENTS REPORT ON PERFORMANCE SCORECARD: TECHNICAL SPECIFICATIONS ............................................................... 2

WAIT TIME FOR SPECIALISTS (WAIT 1) ..................................................................................................................... 4

EMERGENCY VISITS FOR CONDITIONS THAT COULD BE TREATED IN ALTERNATIVE PRIMARY CARE SETTING .......... 6

PERCENT OF DISCHARGE SUMMARIES SENT FROM HOSPITAL TO COMMUNITY CARE PROVIDER WITHIN 48 HOURS 7

ER REVISITS WITHIN 7 DAYS ................................................................................................................................. 10

READMISSIONS WITHIN 30 DAYS FOR SELECTED CASE MIX GROUPS (CMGS) ........................................................ 12

PERCENT OF PEOPLE SEEING PRIMARY CARE PROVIDER WITHIN 7 DAYS OF DISCHARGE FROM HOSPITAL .......... 13

ER VISITS FOR FALLS AMONG SENIORS ................................................................................................................ 15

PRESSURE ULCER RELATED HOSPITALIZATIONS .................................................................................................. 17

HOSPITAL-ASSOCIATED CLOSTRIDIUM DIFFICILE INFECTIONS (CDI) RATE ............................................................. 20

CASES COMPLETED WITHIN PRIORITY TARGETS FOR IMAGING PROCEDURES ...................................................... 21

VARIANCE FROM HBAM EXPECTED COST ............................................................................................................. 23

ALC RATE (INPATIENT DAYS) ................................................................................................................................. 26

GENERAL NOTES ON BIG DOTS ............................................................................................................................. 28

BIG DOT 1: INCREASING THE AVAILABILITY OF FAMILY HEALTH CARE .................................................................... 29

BIG DOT 2: REDUCING EMERGENCY ROOM VISITS ................................................................................................ 31

BIG DOT 3: INCREASING AVAILABILITY AND ACCESS TO COMMUNITY SUPPORTS FOR PEOPLE .............................. 33

BIG DOT 3 REFERENCE: ALC RATE ........................................................................................................................ 36

BIG DOT 3 REFERENCE: READMISSIONS FOR SELECTED CASE MIX GROUPS (CMGS) ............................................ 36

BIG DOT 3 REFERENCE: LENGTH OF STAY FOR HIP REPLACEMENT SURGERY ....................................................... 36

BIG DOT 3 REFERENCE: LENGTH OF STAY FOR KNEE REPLACEMENT SURGERY ................................................... 36

KEY DRIVER 1: INCREASE THE COMMUNICATION BETWEEN HEALTH CARE PROVIDERS THROUGH SPIRE/HRM ...... 37

KEY DRIVER 2: INCREASE PROVIDERS USING CLINICAL CONNECT ........................................................................ 39

KEY DRIVER 3: INCREASE ORGANIZATIONS USING THE ‘REGIONAL INTEGRATED DECISION SUPPORT SYSTEM’ (2013-14) ............................................................................................................................................................... 41

KEY DRIVER 4: INCREASE THE PROPORTION OF KEY INITIATIVES (P4R, BSO, ATC, P4Q) MEETING LHIN EXPERIENCE BASED DESIGN CRITERIA ...................................................................................................................................... 43


Indicator in technical specification Indicator from Balanced Scorecard WAIT TIME FOR SPECIALISTS (WAIT 1) Reduce wait time to specialist from family health care

EMERGENCY VISITS FOR CONDITIONS THAT COULD BE TREATED IN ALTERNATIVE PRIMARY CARE SETTING

Reduce rate of ER visits best managed elsewhere (per 1,000 population aged 1-74)

PERCENT OF DISCHARGE SUMMARIES SENT FROM HOSPITAL TO COMMUNITY CARE PROVIDER WITHIN 48 HOURS

Increase percent of discharge summaries sent from hospital to community care provider within 48 hours

ER REVISITS WITHIN 7 DAYS Reduce ER revisit rates within 7 days (per total unscheduled emergency visits)

READMISSIONS WITHIN 30 DAYS FOR SELECTED CASE MIX GROUPS (CMGS)

Reduce hospital readmission rate within 30 days for selected CMGs (per 100 discharges for selected CMGs)

PERCENT OF PEOPLE SEEING PRIMARY CARE PROVIDER WITHIN 7 DAYS OF DISCHARGE FROM HOSPITAL

Increase percent of clients seeing family health care provider within 7 days of discharge (from hospital)

ER VISITS FOR FALLS AMONG SENIORS Reduce rate of ER visits resulting from falls (per 100,000 population aged 65 and over)

PRESSURE ULCER RELATED HOSPITALIZATIONS Reduce pressure ulcer related hospitalizations (percent of all discharges)

HOSPITAL-ASSOCIATED CLOSTRIDIUM DIFFICILE INFECTIONS (CDI) RATE

Reduce hospital acquired infection rates (c diff) (per 1,000 patient days)

CASES COMPLETED WITHIN PRIORITY TARGETS FOR IMAGING PROCEDURES Increase timeliness of diagnostic services (percent within target)

VARIANCE FROM HBAM EXPECTED COST Reduce LHIN cost variance (HBAM hospitals) for acute/day surgery and ER (actual/expected costs)

ALC RATE (INPATIENT DAYS) Reduce ALC rate (per total inpatient days)

BIG DOT 1: INCREASING THE AVAILABILITY OF FAMILY HEALTH CARE

Big Dot 1: increasing the availability of family health care

BIG DOT 2: REDUCING EMERGENCY ROOM VISITS Big Dot 2: reducing emergency room visits

BIG DOT 3: INCREASING AVAILABILITY AND ACCESS TO COMMUNTIY SUPPORTS FOR PEOPLE

Big Dot 3: increasing availability and access to communtiy supports for people

KEY DRIVER 1: INCREASE THE COMMUNICATION BETWEEN HEALTH CARE PROVIDERS THROUGH SPIRE/HRM

Key Driver 1: Increase the communication between health care providers through SPIRE/HRM

KEY DRIVER 2: INCREASE PROVIDERS USING CLINICAL CONNECT Key Driver 2: Increase providers using Clinical Connect

KEY DRIVER 3: INCREASE ORGANIZATIONS USING THE ‘REGIONAL INTEGRTATED DECISION SUPPORT SYSTEM’ (2013-14)

Key Driver 3: Increase organizations using the ‘Regional Integrated Decision Support System’ (2013-14)

KEY DRIVER 4: INCREASE THE PROPORTION OF KEY INITIATIVES (P4R, BSO, ATC, P4Q) MEETING LHIN EXPERIENCE BASED DESIGN CRITERIA

Key Driver 4: Increase the proportion of key initiatives (P4R, BSO, ATC, P4Q) meeting LHIN Experience Based Design criteria

Note: In some cases, an indicator on the Balanced Scorecard is based on the Ministry of Health and Long-Term Care (MOHLTC) defined technical specifications. The column on the left in the table above will note the MOHLTC’s name of the indicator and the column on the right notes the name of the indicator on the Balanced Scorecard.


WAIT TIME FOR SPECIALISTS (WAIT 1) IN

DICA

TOR

DESC

RIPT

ION

INDICATOR NAME WAIT TIME FOR SPECIALISTS (WAIT 1)

INDICATOR DESCRIPTION

Detailed description of indicator Wait time from the date the specialist received the referral to the consult date

INDICATOR CLASSIFICATION

PERFORMANCE STANDARD

Target: TBD

Corridor: TBD

NUME

RATO

R

CALCULATION TBD

DATA SOURCE TBD

EXCLUSION/INCLUSION CRITERIA

Includes:

TBD

DENO

MINA

TOR

CALCULATION TBD

DATA SOURCE TBD


Includes:

TBD

GEOG

RAPH

Y &

TIMI

NG

TIMING/FREQUENCY OF RELEASE

How often, and when, are data being released?

Reported: TBD

Timeliness: TBD

LEVELS OF COMPARABILITY TBD

TRENDING TBD


Years available for trending AD

DITI

ONAL

INFO

RMAT

ION

LIMITATIONS

Specific limitations TBD

COMMENTS

Additional information regarding the calculation, interpretation, data source, etc.

TBD

REFERENCES

Provide URLs of any key references E.g. Diabetes in Canada, HTTP://....

TBD

RESPONSIBILITY FOR REPORTING TBD

DATE CREATED (YYYY-MM-DD) 2013-05-03

DATE LAST REVIEWED (YYYY-MM-DD) 2013-05-03


EMERGENCY VISITS FOR CONDITIONS THAT COULD BE TREATED IN ALTERNATIVE PRIMARY CARE SETTING

INDICATOR NAME EMERGENCY VISITS FOR CONDITIONS THAT COULD BE TREATED IN ALTERNATIVE PRIMARY CARE SETTING

http://www.health.gov.on.ca/en/pro/programs/ris/docs/emergency_visits_that_could_be_treated_in_alternative_primary_care_setting_en.pdf




PERCENT OF DISCHARGE SUMMARIES SENT FROM HOSPITAL TO COMMUNITY CARE PROVIDER WITHIN 48 HOURS

INDI

CATO

R DE

SCRI

PTIO

N

INDICATOR NAME PERCENT OF DISCHARGE SUMMARIES SENT FROM HOSPITAL TO COMMUNITY CARE PROVIDER WITHIN 48 HOURS


Detailed description of indicator

Percentage of patients discharged from hospital for which discharge summaries are delivered to primary care provider within 48 hours of discharge from hospital.



Target: 100%

Corridor: TBD

NUME

RATO

R

CALCULATION

Number of patients discharged from hospitals for whom a discharge summary is sent via Southwest Physician Office Interface to Regional EMR (SPIRE) to primary care provider within 48 hours of discharge. Number of patients discharged from hospitals for whom a discharge summary is signed within 48 hours of discharge and due to be sent by fax is also included for Cerner South hospitals.

DATA SOURCE

SPIRE transactional data and hospital patient registration system (separate reports from each of the 3 SPIRE hubs: Cerner North, Meditech, and Cerner South. Reports generated from each of the hubs are emailed to the LHIN each month.


Includes: 1. South West LHIN hospital inpatient discharge summaries sent by

SPIRE. Therefore, includes only inpatients whose primary care provider is enrolled in SPIRE. For Cerner South hospitals, discharge summaries are also included if they are sent via fax, regardless of whether or not the physician is enrolled in SPIRE.

Excludes: 1. Discharges from non-South West LHIN hospitals. 2. Inpatient discharge summaries not dictated or transcribed or those

sent to primary care providers by means other than SPIRE (faxes are included for Cerner South).

3. Discharges of inpatients whose primary care provider is not enrolled in SPIRE. In the case of Cerner South, faxed summaries are included.

4. ER patients.

DENO

MIN

ATOR

CALCULATION Number of inpatient discharge summaries sent by SPIRE

DATA SOURCE SPIRE transactional data and hospital patient registration system (separate reports from each of the 3 SPIRE hubs: Cerner North, Meditech, and Cerner


South. Reports generated from each of the hubs are emailed to the LHIN each month.


Includes: 1. South West LHIN hospital inpatient discharge summaries sent by

SPIRE. Therefore, includes only inpatients whose primary care provider is enrolled in SPIRE. For Cerner South, faxed discharge summaries are included as well, regardless of whether or not the provider is enrolled in SPIRE.

Excludes: 1. Discharges from non-South West LHIN hospitals. 2. Inpatient discharge summaries not dictated or transcribed or those

sent to primary care providers by means other than SPIRE (faxes are included for Cerner South).

3. Discharges of inpatients whose primary care provider is not enrolled in SPIRE. In the case of Cerner South, faxed summaries are included.

4. ER patients.

GEOG

RAPH

Y &

TIMI

NG



Reported: Monthly

Timeliness: Available within five days of the end of month for Cerner North and within seven days of the end of the month for Cerner South. HPHA Meditech data is available within 3 days of the end of the month.

LEVELS OF COMPARABILITY Comparison is possible between South West LHIN hospitals but no comparator data available beyond the South West LHIN.

TRENDING Years available for trending

Data are available as of January 2013 for Cerner North, November 2013 for Cerner South, and February 2014 for Meditech.

ADDI

TION

AL IN

FORM

ATIO

N

LIMITATIONS Specific limitations

Includes only discharges sent by SPIRE (and fax for Cerner South). Discharge summaries sent by autofax are likely delivered as quickly to primary care providers as those sent via SPIRE, but transmission date information is not available for autofax. Discharge summaries sent to physicians not enrolled are not included either (except in the case of Cerner South and summaries sent by fax). Therefore overall percent of discharge summaries sent within 48 hours has to be estimated from those sent by SPIRE (and fax for Cerner South).

COMMENTS Additional information regarding the calculation, interpretation, data source, etc.

This indicator assumes that the likelihood of completing dictation and transcription is no different for summaries of patients whose primary care providers are enrolled in SPIRE than for patients whose primary care providers are not enrolled. If evidence surfaces that this is not a valid assumption, the estimate of the overall percentage can be adjusted based on the known percent of discharges sent via SPIRE and the new information about the increased/decreased likelihood of completion of non-SPIRE summaries within 48 hours. For example, if the percent of discharge summaries sent by SPIRE is 60% of all discharges and the proportion sent within 48 hours is 30% (Cerner North, May 2013) and there is no evidence to suggest that non-SPIRE discharges are dictated/transcribed any more quickly than SPIRE discharges, one can safely assume that overall, 30% discharge summaries are sent within 48 hours. However, if one assumes that non-SPIRE summaries are twice as


likely to be completed within 48 hours, then the overall percent sent within 48 hours is more likely to be 30% of the SPIRE summaries (i.e. 60%) PLUS 60% of the non-SPIRE summaries (i.e. 40%) or 18% + 24% or 42%. In April 2014, the SPIRE summaries represented 61.9% of all discharges at Cerner North hospitals, 35.5% of Cerner South discharges (including fax and SPIRE), and 42.8% of all discharges at Meditech hospitals.

REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, HTTP://....

RESPONSIBILITY FOR REPORTING SPIRE hubs (i.e. Cerner North, Meditech, and Cerner South)




ER REVISITS WITHIN 7 DAYS IN

DICA

TOR

DESC

RIPT

ION

INDICATOR NAME ER REVISITS WITHIN 7 DAYS



Rate of repeat emergency visits occurring within 7 days of a previous visit, presented as a proportion of all unscheduled emergency visits.



Target: TBD

Corridor: TBD

NUME

RATO

R

CALCULATION Number of unscheduled emergency visits in the reporting quarter that followed another visit within 7 days

DATA SOURCE Cancer Care Ontario


Includes:

Excludes: 1. Scheduled ER visits. 2. Visits associated with a Health Care Number ‘0’, ‘1’. 3. Visits associated with a province of ‘99’ or ‘CA’ who issues Health

Card. 4. Duplicate visits with the same Health Care Number and ER

registration data/time.

DENO

MINA

TOR

CALCULATION Total number of unscheduled emergency visits in the reporting quarter

DATA SOURCE Cancer Care Ontario


Includes:

Excludes: 1. Scheduled ER visits. 2. Visits associated with a Health Care Number ‘0’, ‘1’. 3. Visits associated with a province of ‘99’ or ‘CA’ who issues Health

Card. 4. Duplicate visits with the same Health Care Number and ER

registration data/time.


GEOG

RAPH

Y &

TIMI

NG


How often, and when, are data being released

E.g. Be as specific as possible…..data are released annually in mid-May

Reported: Monthly

Timeliness: Data available upon request from CCO. Data is lagged approximately four months (i.e. September data is available in January).

LEVELS OF COMPARABILITY Can compare between hospitals within the South West LHIN and between LHINs

TRENDING

Years available for trending Data are available as of April 1, 2011 going forward

ADDI

TION

AL IN

FORM

ATIO

N

LIMITATIONS

Specific limitations

COMMENTS


REFERENCES


RESPONSIBILITY FOR REPORTING CCO




READMISSIONS WITHIN 30 DAYS FOR SELECTED CASE MIX GROUPS (CMGS)

INDICATOR NAME READMISSIONS WITHIN 30 DAYS FOR SELECTED CASE MIX GROUPS (CMGS)

http://www.health.gov.on.ca/en/pro/programs/ris/docs/readmission_within_30days_selected_cmgs_en.pdf

http://www.health.gov.on.ca/en/pro/programs/ris/docs/readmission_within_30days_selected_cmgs_en.pdf


PERCENT OF PEOPLE SEEING PRIMARY CARE PROVIDER WITHIN 7 DAYS OF DISCHARGE FROM HOSPITAL

INDI

CATO

R DE

SCRI

PTIO

N

INDICATOR NAME PERCENT OF PEOPLE SEEING PRIMARY CARE PROVIDER WITHIN 7 DAYS OF DISCHARGE FROM HOSPITAL



Percentage of people discharged from hospital for specific conditions who have a primary care encounter within 7 days of discharge



Target: 100%

Corridor: TBD

NUME

RATO

R

CALCULATION

Number of people discharged from hospital for the following conditions that have a primary care encounter within 7 days of discharge from acute inpatient stay: cardiac conditions, congestive heart failure, chronic obstructive pulmonary disease, cerebrovascular accident (i.e., stroke), diabetes, gastrointestinal disorders, and pneumonia.

DATA SOURCE

Data Source(s): Discharge Abstract Database (DAD), CIHI, Claims History Database (CHDB), MOHLTC, extracted from Health Data Server, MOHLTC, May 2012. Actual calculated rate accessed via: The Quarterly: Health Care System Quarterly Reporting for Ministry Senior Management, produced by Health Analytics Branch, Health System Information Management and Investment Division


Includes: 1. Patients discharged after inpatient stay for the following conditions:

cardiac conditions, congestive heart failure, chronic obstructive pulmonary disease, cerebrovascular accident (i.e., stroke), diabetes, gastrointestinal disorders, and pneumonia.

2. First physician visit in office, home, or long-term care home.

Excludes: 1. Follow-up visits made in hospital.

DENO

MINA

TOR CALCULATION

Number of patients discharged after inpatient stay for the following conditions: cardiac conditions, congestive heart failure, chronic obstructive pulmonary disease, cerebrovascular accident (i.e., stroke), diabetes, gastrointestinal disorders, and pneumonia.

DATA SOURCE Data Source(s): Discharge Abstract Database (DAD), CIHI, Claims History Database (CHDB), MOHLTC, extracted from Health Data Server, MOHLTC, May 2012.


Actual calculated rate accessed via: The Quarterly: Health Care System Quarterly Reporting for Ministry Senior Management, produced by Health Analytics Branch, Health System Information Management and Investment Division






GEOG

RAPH

Y &

TIMI

NG



Reported: Biannually (usually released in February and August).

Timeliness: Data is lagged approximately three quarters (August 2013 release only contained data up to Q2 2012/13).

LEVELS OF COMPARABILITY Can compare between LHINs.

TRENDING Years available for trending Data are available as of Q3 2010/11going forward.

ADDI

TION

AL IN

FORM

ATIO

N


Limited to specific conditions (identified above) Limited to primary care providers participating in QIPs


Requires merging of primary care billing data and hospital data (i.e. DAD) and therefore is not possible to calculate locally nor on a monthly basis


The Quarterly, Health Analytics Branch, Health System Information Management and Investment Division. Posted on the Directory of Networks (DoN)

RESPONSIBILITY FOR REPORTING HAB, MOHLTC




ER VISITS FOR FALLS AMONG SENIORS IN

DICA

TOR

DESC

RIPT

ION

INDICATOR NAME ER VISITS FOR FALLS AMONG SENIORS



Rate of ER visits resulting from falls (per 100,000 population aged 65 and older)



Target: TBD

Corridor: TBD

NUME

RATO

R

CALCULATION Total number of ER visits with a fall reported.

DATA SOURCE Data Source(s): National Ambulatory Reporting System (NACRS), CIHI


Includes: 1. Ontario patients (province of residence = ON). 2. ICD10 code in any diagnosis of W00^-W19^ (ICD10 Block = (W00-

W19) (FALLS). 3. Patient age of 65 and older.

Excludes: 1. Patients transferred from other facilities or hospitals, e.g. long-term

care homes.

DENO

MINA

TOR

CALCULATION Population aged 65 and older

DATA SOURCE Data Source(s): Population Estimates and Projections, Statistics Canada & Ontario Ministry of Finance, distributed by Ontario Ministry of Health and Long-Term Care: IntelliHealth Ontario


Includes: 1. Residents of chosen geography.

GEOG

RAPH

Y &

TIMI

NG TIMING/FREQUENCY OF

RELEASE


E.g. Be as specific as possible…..data are released

Reported: Quarterly (NACRS), Annually (Population)

Timeliness: NACRS data is released with an approximate four month delay. Annual population estimates are updated each October.


annually in mid-May

LEVELS OF COMPARABILITY Can compare between sites and LHINs.

TRENDING Years available for trending Data are available as of 2001/02 going forward.

ADDI

TION

AL IN

FORM

ATIO

N

LIMITATIONS Specific limitations N/A


N/A


Indicator based on MOHLTC indicator - http://www.health.gov.on.ca/en/pro/programs/ris/docs/hospitalizations_for_falls_among_seniors_en.pdf




http://www.health.gov.on.ca/en/pro/programs/ris/docs/hospitalizations_for_falls_among_seniors_en.pdf

http://www.health.gov.on.ca/en/pro/programs/ris/docs/hospitalizations_for_falls_among_seniors_en.pdf


PRESSURE ULCER RELATED HOSPITALIZATIONS

INDICATOR NAME PRESSURE ULCER RELATED HOSPITALIZATIONS



Percent of hospitalizations during which a pressure ulcer occurred, either as the most responsible diagnosis, a post-admit comorbidity and/or a pre-existing condition prior to admission


PERFORMANCE STANDARD Target: TBD

Corridor: TBD

NUME

RATO

R

CALCULATION Number of hospitalizations with at least one diagnosis of pressure ulcer in any of the diagnosis fields in the Discharge Abstract Database. Pressure ulcer was inferred from the ICD 10 codes ranging from L890 to L899 (Stausberg & Keiffer, 2009).

DATA SOURCE Hospital Discharge Abstract Database, accessed via IntelliHealth “Pressure Ulcer” query in South West folder of Web Report Studio


Includes:

1. Hospitalizations with an ICD10 code of L89.0 to L89.9 in any diagnosis field.

DENO

MINA

TOR

CALCULATION Number of discharges

DATA SOURCE Hospital Discharge Abstract Database, accessed via IntelliHealth “Pressure Ulcers” query in South West folder of Web Report Studio


Includes:

1. All acute hospital discharges.

GEOG

RAPH

Y &

TIMI

NG




Reported: Monthly

Timeliness: according to updates of DAD in IntelliHealth (scheduled release of data is lagged 4 months from close of quarter).


LEVELS OF COMPARABILITY Comparisons between hospitals and between LHINs.

TRENDING

Years available for trending Data are available for more than 10 years (see DAD in IntelliHealth)

ADDI

TION

AL IN

FORM

ATIO

N

LIMITATIONS

Specific limitations None

COMMENTS


Many estimates of prevalence of pressure ulcers are generated through a point-in-time clinical survey of all patients in a hospital. These surveys, based on the work of the National Pressure Ulcer Advocacy Panel (NPUAP), have been published multiple times since 2001 (Amlung et al., 2001) and have estimated the prevalence of pressure ulcers in acute care hospitals in Canada between 12.8 and 17% (VanDenKerkhof et al., 2011) and between 2 and 29% in the USA (Salcido & Popescu, 2009). One study based on routinely collected hospital discharge abstract data in the USA estimated prevalence of pressure ulcers at 1.43% (Fogarty et al., 2009, p 679).

Both approaches to understanding the prevalence of pressure ulcers consider the presence of ulcers in all patients, regardless of the reason for their hospitalization. Both approaches therefore are consistent with the approach outlined here to include all ulcers in all hospitalizations in estimating prevalence.

However, the two different sources of data described in the literature present remarkably different rates. The rate based on clinical surveys is likely more meaningful clinically whereas the rate based on routinely collected data is more available for sustainable ongoing monitoring. The gap between the estimates highlights the differences between what the two data collection strategies are measuring and suggests that the rates are not comparable. Targets for performance measured using these technical specifications (i.e. routinely collected discharge diagnoses data) can therefore not be based on prevalence estimates based on clinical surveys.

REFERENCES


Amlung, S. R., Miller, W.L., Bosley, L. M., (2001) ‘The 1999 National Pressure Ulcer Prevalence Survey: A Benchmarking Approach’, Advances in Skin & Wound Care, 14 (6), pp 297-301

Fogerty, M., Guy,J., Barbul, A., Nanney, L.B., Abumrad, N.N. (2009) ‘African Americans show increased risk for pressure ulcers: A retrospective analysis of acute care hospitals in America’ Wound Rep Reg, 17, pp 678–684

Salcido R; Popescu A (2009) ‘Pressure Ulcers and Wound Care’ ,Available from: http://emedicine.medscape.com/article/319284-overview), (Accessed Apr 7, 2013)

Stausberg, J., Kiefer, E. (2009) ‘Classification of Pressure Ulcers: A

http://emedicine.medscape.com/article/319284-overview


Systematic Literature Review’, Stud Health Technol Inform.146 pp.511-5.

VanDenKerkhof, E.G., Friedberg, E., Harrison, M.B. (2011) ‘Prevalence and Risk of Pressure Ulcers in Acute Care Following Implementation of Practice Guidelines: Annual Pressure Ulcer Prevalence Census 1994–2008’, Journal for Healthcare Quality, 33(5), pp 58–67

RESPONSIBILITY FOR REPORTING




HOSPITAL-ASSOCIATED CLOSTRIDIUM DIFFICILE INFECTIONS (CDI) RATE

INDICATOR NAME HOSPITAL-ASSOCIATED CLOSTRIDIUM DIFFICILE INFECTIONS (CDI) RATE

http://www.health.gov.on.ca/en/pro/programs/ris/docs/hospital_associated_clostridium_difficile_infections_rate_en.pdf

http://www.health.gov.on.ca/en/pro/programs/ris/docs/hospital_associated_clostridium_difficile_infections_rate_en.pdf


CASES COMPLETED WITHIN PRIORITY TARGETS FOR IMAGING PROCEDURES

INDI

CATO

R DE

SCRI

PTIO

N

INDICATOR NAME CASES COMPLETED WITHIN PRIORITY TARGETS FOR IMAGING PROCEDURES



http://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_completed_within_priority_for_computed_tomography_scans_en.pdf http://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_completed_within_priority_for_mri_scans_en.pdf



Target: TBD

Corridor: TBD

NUME

RATO

R

CALCULATION Wait Days = Procedure Date – Decision to Treat Date – Patient Unavailable Days

DATA SOURCE iPort


Includes:

1. Closed cases submitted by hospitals through the Wait Time Information System (WTIS)

2. Metrics: Completed Cases <= Access Target, Completed Case Volume: MRI/CT, % Cases Completed Within Access Target: MRI/CT

3. Attributes: LHIN 4. Service Area = MRI and CT 5. Priority 2, 3, 4, Unknown and Not Applicable 6. Patients aged 18 years and older

DENO

MINA

TOR

CALCULATION N/A

DATA SOURCE N/A

EXCLUSION/INCLUSION CRITERIA N/A

http://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_completed_within_priority_for_computed_tomography_scans_en.pdf

http://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_completed_within_priority_for_computed_tomography_scans_en.pdf

http://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_completed_within_priority_for_mri_scans_en.pdf

http://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_completed_within_priority_for_mri_scans_en.pdf


GEOG

RAPH

Y &

TIMI

NG



Reported: Quarterly

Timeliness: Data released at the end of the months in April, July, October and January.

LEVELS OF COMPARABILITY Can compare between LHINs and between hospitals but not between primary care providers

TRENDING

Years available for trending Data are available from June 2007

ADDI

TION

AL IN

FORM

ATIO

N

LIMITATIONS


Wait times data submission is voluntary. Hospitals not reporting cases promptly are excluded at the time of data extraction.

COMMENTS


REFERENCES


https://www.cancercare.on.ca/ocs/wait-times/wtio/

RESPONSIBILITY FOR REPORTING Hospitals



https://www.cancercare.on.ca/ocs/wait-times/wtio/


VARIANCE FROM HBAM EXPECTED COST IN

DICA

TOR

DESC

RIPT

ION

INDICATOR NAME VARIANCE FROM HBAM EXPECTED COST



Ratio between actual cost per unit of service and HBAM expected cost (average of the ratio for all HBAM hospitals – each component calculated separately)


PERFORMANCE STANDARD Target: 1.00

Corridor: TBD

NUME

RATO

R

CALCULATION Ratio of difference between actual expenditure per unit of service for each of the components of the HBAM formulae and the expected cost for each component which is generated annually via HBAM formulae.

‘

Actual expenditure per unit of service: total direct nursing costs plus a proportion of indirect costs as reported in each hospital’s quarterly trial balance (generated quarterly by Scott Chambers or delegate) Proportion of indirect costs inferred from the allocation of indirect costs to each HBAM component for the previous fiscal year in the annual financial summary provided by the MOHLTC based on the cumulative trial balances submitted through the year. Units of service: weighted cases for Acute (DAD), Day Surgery and ER components (NACRS), weighted cases for CCC, Rehab and MH (sources are CCRS, NRS and MH inpatient data but not currently being accessed because it is too old for use in scorecard – revisit sourcing from RIDS end of Q3 13/14)


Includes: 1. All clinical activity in functional centres associated with Acute

Inpatient, Day Surgery, CCC, Rehab, ER and inpatient MH as per the linked document.

OCDM Guide_13-14YE_Final

2. All hospitals included by HBAM methodology – as of May 2014, there

are 7: London Health Sciences Centre, Grey Bruce Health Services-Owen Sound, Stratford General Hospital, Woodstock General Hospital, St Thomas Elgin General Hospital, St Joseph’s Health Care, and Strathroy Middlesex General Hospital.

Excludes

1. All non-HBAM hospitals 2. All clinical activity in functional centres other than those specified


above

DENO

MINA

TOR

CALCULATION The expected cost per unit of service generated annually based on HBAM formulae for each component (e.g. Acute and Day surgery, ER, etc.)

DATA SOURCE Annual HBAM calculations from MOHLTC


Includes: 1. All clinical activity in functional centres associated with Acute

Inpatient, Day Surgery, CCC, Rehab, ER and inpatient MH (see above for detail)

2. All hospitals included by HBAM methodology (see above for detail)

Excludes

1. All non-HBAM hospitals 2. All clinical activity in functional centres other than those specified

above

GEOG

RAPH

Y &

TIMI

NG




Reported: quarterly for Q2, Q3 and Q 4 only (no update possible for Q1 as no trial balance ever submitted for Q1)

Timeliness: data submitted by the 7th of the 2nd month following the quarter end (i.e. Q3 ends in December, data submitted by February 7th).

LEVELS OF COMPARABILITY Comparisons between HSPs within SW LHIN only because we have no access to trial balance in other LHINS.

TRENDING Years available for trending Data are available as of 2010 forward

ADDI

TION

AL IN

FORM

ATIO

N


Limited to HBAM hospitals (see above for detail). Not possible to drill down below level of HBAM component (e.g. Acute/day surgery, CCC, etc.) to understand contributing factors to changes (or lack thereof) in performance Actual cost per unit of service is calculated internally by the South West LHIN based on the hospital’s previous year’s distribution of indirect costs between HBAM components. For example, the amount of laboratory costs attributed to CCC patients divided by the direct costs for CCC patients (e.g. nursing costs) is used to determine how much laboratory costs to attribute to the quarterly total direct nursing costs for CCC to estimate the actual cost per unit of CCC service. It is possible that the allocation used to distribute indirect costs to various HBAM components in the current year is not the same as that used in the previous


year. However, there is no current data on the distribution and this is the distribution used by MOHLTC throughout the year so it is rational to use this in these calculations.


The goal is to decrease the variance to achieve a ratio of 1 or less (i.e. actual cost is less than expected).


References available on the Health Data Branch web portal (hsimi.on.ca)

RESPONSIBILITY FOR REPORTING Health Service Providers




ALC RATE (INPATIENT DAYS) IN

DICA

TOR

DESC

RIPT

ION

INDICATOR NAME ALC RATE (INPATIENT DAYS)



Reports on ALC patients that are still waiting in a hospital bed (open) and ALC patients that have been discharged/discontinued (closed) during the time period.



Target: TBD

Corridor: TBD

NUME

RATO

R CALCULATION

The total ALC days represents the total number of ALC days contributed by ALC patients within the specific reporting month/quarter. Inpatient service type is identified in the WTIS.

ALC days for Inpatient Services NS + SU + IC

DATA SOURCE WTIS-ALC Data Cut


Excludes: 1. Hospitals that do not report to both the WTIS and the BCS 2. Inpatient days in “Emergency room” bed type 3. ALC cases discontinued due to ‘Data Entry Error’. 4. ALC cases having Inpatient Service = Discharge Destination for Post-

Acute Care (*Exception: Bloorview Rehab, CCC to CCC). 5. ALC cases identified by the facility for exclusion.

DENO

MINA

TOR

CALCULATION The total patient days represents the total number of patient days contributed by inpatients within the specific reporting month/quarter. Bed type is identified in the BCS data submission. Acute Patient days = Med + Surg + CMS + ICU + OBS + PAE + Pediatrics in Nursery + Newborns

DATA SOURCE

Bed Census Summary (BCS) [previously the Daily Census Summary (DCS)].

Ontario hospitals make monthly data submissions to the ministry’s Health Data Branch (HDB) Web Portal. ATC then takes a data cut from the Web Portal to use for the total patient days in the ALC Rate Report.


Excludes:

Patient days contributed by inpatients in the emergency department (Bed Type


= Emergency) GE

OGRA

PHY

& TI

MING




Reported: Quarterly

Timeliness: 6th business day following the last reporting month in the quarter

LEVELS OF COMPARABILITY Can compare between hospitals within the South West LHIN and between LHINs

TRENDING

Years available for trending Data are available as of July 2011

ADDI

TION

AL IN

FORM

ATIO

N

LIMITATIONS

Specific limitations Limited to hospitals reporting into WTIS and BCS.

COMMENTS


Methodology Notes from Supplemental Material for the Quarterly Stocktake Report (produced by CCO) (basis for this technical specification)

The day of ALC designation is counted as an ALC day but the date of discharge or discontinuation is not counted as an ALC day.

For cases with an ALC designation date on the last day of a reporting period and no discharge/discontinuation date, then ALC days = 1.

The ALC Rate indicator methodology makes the assumption that the Inpatient Service data element (as defined in the WTIS) is comparable to the Bed Type data element (as defined in the BCS).

REFERENCES


Supplemental Material for the Quarterly Stocktake Report can be found on the Directory of Networks (DoN), within the Quarterly Performance and Stocktake Reports folder.

RESPONSIBILITY FOR REPORTING CCO via Stocktake supplemental report




General Notes on Big Dots

1) Targets for Big Dots were set in Fall 2012 based on data available at that time. 2) The following principles were used to define targets:

a. Big Dot 1: 5% increase over baseline rate of patients discharged from hospital seen by family physician within 7 days of discharge (based on most recent 4 quarters of data available as of Aug 2013: Q3 2010/11-Q2 2011/12).

b. Big Dot 2: 5% reduction from baseline rate (2011/12) in ER revisits within 7 days, per HQO and MOHLTC approach to setting targets for improvements and given that there are no other existing targets for this indicator.

c. Big Dot 3: reduction in ALC days from baseline rate (2011/12) to MLPA target, elimination of the gap between actual and expected readmission rates for selected CMGs, and 5% reduction in LOS in hip and knee surgery from baseline rate (2011/12). Note: in February 2014, the decision was made to move from ALC days to ALC rate as ALC rate includes acute and post-acute. The target, however, was not changed.

3) Progress on Big Dots is measured from Q1 2013/14 going forward since that is the time period for the IHSP initiative, which the Big Dots are intended to track the impact of.

4) Progress on Big Dots is measured as cumulative improvement over baseline performance. Baseline performance is either the MLPA baseline for 2013/14 or, if not available, the most recent 4 quarters of data available as of Apr 2013. This means that the baseline period is not the same for all components of the Big Dots. It also means that baseline will not be the performance level at the time the target was calculated. This is because changes in performance between the time the target was calculated and April 2013 should not be attributed to progress with the new IHSP because the IHSP was first launched in April 2013, not prior to that.

5) Unlike reporting on most of the other Scorecard indicators, progress on Big Dots will NOT be measured on the data available during the time period of interest but rather on the data that describe that time period. Another difference is that progress on Big Dots is cumulative over each following time period rather than being point estimates for performance at a particular time. For example, if there were 100 revisits prevented in Q1 and 250 in Q2, the progress on this Big Dot would be reported as 350 on whatever date that Q2 data were available, which could be Q4 or later.

6) The process for calculating progress on Big Dots is detailed in the following technical specifications.


BIG DOT 1: INCREASING THE AVAILABILITY OF FAMILY HEALTH CARE IN

DICA

TOR

DESC

RIPT

ION INDICATOR NAME

BIG DOT 1: INCREASING THE AVAILABILITY OF FAMILY HEALTH CARE


Detailed description of indicator Cumulative total of the number of patients seen by primary care provider within 7 days of discharge from inpatient stay for specific conditions


PERFORMANCE STANDARD Target: 5% improvement over baseline

Corridor: n/a

NUME

RATO

R

CALCULATION

Number of people discharged from hospital for the following conditions that have a primary care encounter within 7 days of discharge from acute inpatient stay: 25 CMGs covering cardiac conditions, congestive heart failure, chronic obstructive pulmonary disease, cerebrovascular accident (i.e., stroke), diabetes, gastrointestinal disorders, and pneumonia.

DATA SOURCE

Data Source(s): Discharge Abstract Database (DAD), CIHI, Claims History Database (CHDB), MOHLTC, extracted from Health Data Server, MOHLTC, May 2012. Actual calculated rate accessed via: The Quarterly: Health Care System Quarterly Reporting for Ministry Senior Management, produced by Health Analytics Branch, Health System Information Management and Investment Division






DENO

MINA

TOR CALCULATION TBD

DATA SOURCE TBD


TBD

GEOG

RAPH

Y &

TIMI

NG


How often, and when, are data

Reported: Biannually (usually released in February and August).

Timeliness: Data is lagged approximately three quarters (August 2013 release only contained data up to Q2 2012/13).


being released


LEVELS OF COMPARABILITY Not comparable to anything (i.e. no cross-LHIN data)

TRENDING Years available for trending Data are available as of Q3 2010/11going forward.

ADDI

TION

AL IN

FORM

ATIO

N


Limited to specific conditions (identified above) Limited to primary care providers participating in QIPs


Requires merging of primary care billing data and hospital data (i.e. DAD) and therefore is not possible to calculate locally nor on a monthly basis


The Quarterly, Health Analytics Branch, Health System Information Management and Investment Division. Posted on the Directory of Networks (DoN)





BIG DOT 2: REDUCING EMERGENCY ROOM VISITS IN

DICA

TOR

DESC

RIPT

ION INDICATOR NAME

BIG DOT 2: REDUCING EMERGENCY ROOM VISITS



Cumulative total of revisits reduced through reduction the % of ER revisits within 7 days (based on ER REVISITS WITHIN 7 DAYS)


PERFORMANCE STANDARD Target: 15,000 visits prevented from April 1, 2013 to March 31, 2016

Corridor: n/a

NUME

RATO

R

CALCULATION

The difference between the current and baseline ER revisit rate multiplied by the total number of ER visits (not revisits) in the current quarter (i.e. (Q1Rate-Baseline)/Total Q1 ER Visits)

The number of revisits prevented in a quarter is added to the revisits prevented in previous quarters to generate a cumulative total from baseline forwards.

DATA SOURCE See ER REVISITS WITHIN 7 DAYS

EXCLUSION/INCLUSION CRITERIA See ER REVISITS WITHIN 7 DAYS

DENO

MINA

TOR CALCULATION N/A

DATA SOURCE N/A


N/A

GEOG

RAPH

Y &

TIMI

NG




Reported: Quarterly

Timeliness: see ER REVISITS WITHIN 7 DAYS

LEVELS OF COMPARABILITY Not comparable to any other LHIN

TRENDING Years available for trending See ER RE-VISITS WITHIN 7 DAYS OF ER VISITS


ADDI

TION

AL IN

FORM

ATIO

N LIMITATIONS Specific limitations See ER RE-VISITS WITHIN 7 DAYS OF ER VISITS


Target was set on the basis of a 5% reduction in revisits for 3 years over the 2010/11 rate.


RESPONSIBILITY FOR REPORTING See ER RE-VISITS WITHIN 7 DAYS




BIG DOT 3: INCREASING AVAILABILITY AND ACCESS TO COMMUNITY SUPPORTS FOR PEOPLE

INDI

CATO

R DE

SCRI

PTIO

N

INDICATOR NAME BIG DOT 3: INCREASING AVAILABILITY AND ACCESS TO COMMUNTIY SUPPORTS FOR PEOPLE



Cumulative total of hospitalization days reduced through reduction of ALC rate, reduced readmissions for selected CMGs, and reduced length of stay for total hip/knee joint replacements (total joint replacements)


PERFORMANCE STANDARD Target: 17,000 or 36,000 days saved from April 1, 2013 to March 31, 2016 (see comments below)

Corridor: n/a

NUME

RATO

R CALCULATION

ALC

The difference between the current and baseline ALC rate multiplied by the total inpatient days (not ALC days) in the current quarter. Baseline is established as the 2012/13 fiscal year.

READMISSIONS

The number of hospitalizations prevented is the difference in the gap between the expected and actual readmission rates relative to the baseline gap multiplied by the total number of index visits in the current quarter (see READMISSIONS FOR SELECTED CASE MIX GROUPS (CMGs)). Multiply the number of hospitalizations by the average LOS for these CMGs (10.8 days circa calculation of the target) to generate the number of days prevented.

(Current gap – baseline gap) * current index cases * average LOS at baseline = additional readmits prevented through improvements over baseline in readmission rate

LOS FOR HIP/KNEE TOTAL JOINT REPLACEMENTS (TJR)

The difference between the current and baseline average LOS for hip/knee TJR is multiplied by the total number of discharges for hip/knee TJR in the current quarter. Baseline will be set as the average LOS for 2012/13 when it becomes available. For interim reporting of progress (i.e. prior to availability of 2013/14 data), baseline is set as average LOS for 2011/12.

CUMULATIVE TOTAL

The number of hospitalization days prevented in a quarter is added to the days prevented in previous quarters to generate a cumulative total from baseline forwards.

DATA SOURCE See each of the source indicators (i.e. ALC rate, readmissions and hip/knee joint replacement)



See each of the source indicators (i.e. ALC rate, readmissions and hip/knee joint replacement)

DENO

MINA

TOR CALCULATION n/a

DATA SOURCE n/a


n/a

GEOG

RAPH

Y &

TIMI

NG




Reported: Quarterly

Timeliness: See each of the source indicators (i.e.ALC Rate, Readmissions for Selected Case Mix Groups, and Wait Times for Hip/Knee Replacement Surgery)

LEVELS OF COMPARABILITY Not comparable to any other LHIN

TRENDING

Years available for trending

See each of the source indicators (i.e. ALC Rate, Readmissions for Selected Case Mix Groups, and Wait Times for Hip/Knee Replacement Surgery)

ADDI

TION

AL IN

FORM

ATIO

N

LIMITATIONS



COMMENTS


REFERENCES






BIG DOT 3 REFERENCE: ALC RATE

INDICATOR NAME ALC RATE

See ALC Rate definition above.

BIG DOT 3 REFERENCE: READMISSIONS FOR SELECTED CASE MIX GROUPS (CMGS)

INDICATOR NAME READMISSIONS FOR SELECTED CASE MIX GROUPS (CMGS)

See Readmissions for Selected Case Mix Groups (CMGs) definition above.

BIG DOT 3 REFERENCE: LENGTH OF STAY FOR HIP REPLACEMENT SURGERY

INDICATOR NAME LENGTH OF STAY FOR HIP REPLACEMENT SURGERY

Based on the cohorts developed from the Quality Based Procedures Handbook.

QBP Clinical Handbook Primary Un

BIG DOT 3 REFERENCE: LENGTH OF STAY FOR KNEE REPLACEMENT SURGERY

Based on the cohorts developed from the Quality Based Procedures Handbook.

QBP Clinical Handbook Primary Un


KEY DRIVER 1: INCREASE THE COMMUNICATION BETWEEN HEALTH CARE PROVIDERS THROUGH SPIRE/HRM

INDI

CATO

R DE

SCRI

PTIO

N INDICATOR NAME KEY DRIVER 1: INCREASE THE COMMUNICATION BETWEEN HEALTH CARE PROVIDERS THROUGH SPIRE/HRM


Detailed description of indicator Proportion of South West LHIN clinicians enrolled in SPIRE/HRM


PERFORMANCE STANDARD Target:

Corridor:

NUME

RATO

R

CALCULATION Number of South West LHIN nurse practitioners and primary care physicians enrolled in SPIRE/HRM

DATA SOURCE Data provided by the South West LHIN eHealth team each quarter.


Includes: 1. Primary care physicians and nurse practitioners in the South West

LHIN

DENO

MINA

TOR

CALCULATION Number of South West LHIN nurse practitioners and primary care physicians



Includes: 1. Primary care physicians and nurse practitioners in the South West

LHIN

GEOG

RAPH

Y &

TIMI

NG




Reported: Upon request

LEVELS OF COMPARABILITY


TRENDING


ADDI

TION

AL IN

FORM

ATIO

N

LIMITATIONS

Specific limitations Represents a point in time number.

COMMENTS


REFERENCES






KEY DRIVER 2: INCREASE PROVIDERS USING CLINICAL CONNECT IN

DICA

TOR

DESC

RIPT

ION INDICATOR NAME

KEY DRIVER 2: INCREASE PROVIDERS USING CLINICAL CONNECT


Detailed description of indicator Proportion of South West LHIN providers using Clinical Connect



Corridor:

NUME

RATO

R

CALCULATION Number of South West LHIN providers using Clinical Connect



Includes: 1. Providers using Clinical Connect in the South West LHIN

DENO

MINA

TOR

CALCULATION Number of South West LHIN providers



Includes: 1. Providers in the South West LHIN

GEOG

RAPH

Y &

TIMI

NG




Reported: Upon request


TRENDING



ADDI

TION

AL IN

FORM

ATIO

N LIMITATIONS


COMMENTS


REFERENCES






KEY DRIVER 3: INCREASE ORGANIZATIONS USING THE ‘REGIONAL INTEGRATED DECISION SUPPORT SYSTEM’ (2013-14)

INDI

CATO

R DE

SCRI

PTIO

N INDICATOR NAME KEY DRIVER 3: INCREASE ORGANIZATIONS USING THE ‘REGIONAL INTEGRATED DECISION SUPPORT SYSTEM’ (2013-14)



Proportion of eligible South West LHIN health service providers (currently hospitals and the CCAC) with all data submissions up to date in the Regional Integrated Decision Support (RIDS) system.



Corridor:

NUME

RATO

R

CALCULATION Number of South West LHIN health service providers with all data submissions up to date as denoted by ‘Up to Date’ submissions on the Submissions tab of IDS.

DATA SOURCE Data pulled by Lindsey Declercq after the last data upload (Wednesday nights) before the Scorecard is due to be released.


Includes: 1. Providers submitting data to RIDS in the South West LHIN (currently

all hospitals and the CCAC).

DENO

MINA

TOR

CALCULATION Number of South West LHIN health service providers submitting data to RIDS (currently all hospitals and the CCAC).

DATA SOURCE Data pulled from RIDS


Includes: 1. Providers submitting data to RIDS in the South West LHIN (currently

all hospitals and the CCAC).

GEOG

RAPH

Y &

TIMI

NG




Reported: Data can be accessed as frequently as desired.



TRENDING


ADDI

TION

AL IN

FORM

ATIO

N

LIMITATIONS


COMMENTS


REFERENCES






KEY DRIVER 4: INCREASE THE PROPORTION OF KEY INITIATIVES (P4R, BSO, ATC, P4Q) MEETING LHIN EXPERIENCE BASED DESIGN CRITERIA

INDI

CATO

R DE

SCRI

PTIO

N INDICATOR NAME KEY DRIVER 4: INCREASE THE PROPORTION OF KEY INITIATIVES (P4R, BSO, ATC, P4Q) MEETING LHIN EXPERIENCE BASED DESIGN CRITERIA


Detailed description of indicator Number of criteria met by Pay For Results, Behavioural Supports Ontario, Access To Care, and Partnering For Quality



Corridor:

NUME

RATO

R

CALCULATION Number of criteria met by Pay For Results, Behavioural Supports Ontario, Access To Care, and Partnering For Quality

DATA SOURCE Data requested from each of the Project Leads by Nicole Robinson


Criteria Includes: 1. Continuous plans to capture patient experience 2. Continuous incorporation of patient experience feedback 3. Actively engaged patients involved in co-designing improvements 4. Continuous implementation of co-design improvement opportunities 5. Communication, monitoring, and reporting of patient experience 6. Spread within organizations participating in the above noted programs

DENO

MINA

TOR

CALCULATION Number of potential criteria attainable by Pay For Results, Behavioural Supports Ontario, Access To Care, and Partnering For Quality

DATA SOURCE Data requested from each of the Project Leads by the Team Lead, Performance Improvement


Includes: 1. Criteria as above for each of the 4 organizations for a total of 24 for

the denominator

GEOG

RAPH

Y &

TIMI

NG




Reported: Data updated upon request



TRENDING


ADDI

TION

AL IN

FORM

ATIO

N

LIMITATIONS


COMMENTS


REFERENCES





balanced scorecard technical specification

Documents