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PHC Annual Performance Report 2009/2010

Last revised: July 19, 2010

Holy Family Hospital

Mount Saint Joseph Hospital

St. Paul's Hospital

St. Vincent's Hospitals: Brock Fahrni, Langara, Honoria

Conway ‐ Heather

Youville Residence

Marion Hospice

Community Dialysis Clinics: Sechelt, Richmond, Powell

River, Squamish, North Shore, Vancouver

07/08 09/10 10/1108/09

Apr 1 2007New CMG+Grouper isintroduced

Sep 19 2007GI outbreakon SPH 9A for4 days

Oct 15 2007SPH ED Fast Track renovationsare completed

Mar 28 2008Outpatient DeptRenovation Project starts at SPH

JanOctJulApr1 1312111098765432

JanOctJulApr JanOctJulApr1 1312111098765432 1 1312111098765432

Oct 5 2007GI outbreakon SPH 9A for6 days

Mar 7 2008GI outbreak on MSJ 3W for 10 days

Oct 2 2007CollaborativeNursing PracticeInitiative begins on SPH10A/B

Oct 1 2007PHC begins toreceive the services of two thoracic surgeonsshared with VCH

Months

Fiscal Periods

Apr 19 2008GI outbreak on SPH9C/D for 4 days

Apr 25 2008Norovirus Outbreak on SPH 9C/D and 7C/D for 3 days and on 7A/B for 10 days

May 25 2007Yearly update of ADT occurs -06/07 numbersare affected dueto corrections

Oct 5 2007Code Silver,InformationSystems for 2 days

Jan 1 2008Hospitalist servicebegins at MSJ for a one-year trial

May 1 2008Regional Sunquest Laboratory Systemis implemented atPHC

Jun 16 2008Renovation Of MSJ 3W begins

Jul 25 2008Comox QuietRoom at SPH ED is reclassified asa Mental Health inpatient unit

Mar 24 2009Influenza Aoutbreak onHFH ECU2 For 7 days

Mar 23 2009GI outbreak onBF4 for 16 days

Mar 16 2009GI outbreak onall floors atYouville for 11days

Mar 16 2009GI outbreak onSPH 2E for4 days

Mar 9 2009GI outbreak on 4E MSJ for 8days

Feb 23 2009GI outbreak on SPH 7D for 7 days

Jan 30 2009GI outbreak on SPH 9A for 15 daysSep 19 2007

Revised Do Not Attempt Resuscitationand Options for Care Policies go into effect

May 15 2007End of IPD outbreak

May 23 2007Rotavirus outbreak on 10C for 8 days Feb 6 2009

Transition from ADTSystem to Access Manager occurs

Nov 23 2007Rollout of initiatives to reduce in-hospital fractures, including SAFESTEP

Jun 1 2009teamCare Providencecommences atMSJ 1 South

Jul 1 200913 Medicine beds closed at MSJ

Jul 3 2009Breast HealthOncology Clinicopens at SPH

Jul 13 2009Seasonal closureof 46 beds atSPH (untilSep 13, 2009)

Sep 4 2009Geriatric Day Hospital atSPH closed

Sep 14 20095 surgery beds closed

Oct 28 2009Peak of ED visits associated withinfluenza-like illnessNov 4 2009Peak of total number of patients in hospital with H1N1Dec 18 2009Seasonal closure of 39 beds at SPH

Feb 1 2010GI outbreakat St. VincentHosptial LangaraCedar Unit for 19 days

Dec 31 2009Discontinuation ofHospitalist ProgramIn Department ofMedicine at SPH

Feb 11 2010Closure of 6 Surgery beds on8C until Mar 14Feb 12 2010Vancouver WinterOlympics

Mar 12 2010Vancouver WinterParalympicsMar 23 2010SPH 2E renamedthe PASU(PsychiatricAssessment andStabilization Unit

Mar 23 2010Norovirusoutbreak onMSJ ECU for22 days

Jan 15 2009teamCare Providencecommences on MSJMedicine units

Jan 13 2010teamCare ProvidenceCommences atSPH 9A

Mar 30 2010teamCareProvidencecommenceson SPH 4NWand SPHMedicine

Jul 1 2009Seasonal closureof 7 beds atMSJ (untilSep 8, 2009)

Jan 4 20108 Medicine beds moved from SPH 9CD to 8A

Jan 4 20107 Gerimed beds closed at SPH 9CD

Table of Contents

Prepared by Administrative Decision Support PHC Annual Performance Report 09/10 1

Performance Summary ……………………………………………………………………….…………… 2

A Day in the Life of PHC ……………………………………………………………………….…………… 5

Background ………………………………………………………………….………….…………….…… 6 Introduction …………………………………………………………………………………………………… 6Balanced Scorecard …………………………………………………………………………………………… 6PHC Balanced Scorecard Renewal …………………………………………………………………………… 6Selection of PHC Performance Indicators ……..…………………………………………………………… 7Indicator Limitations ………………………………………………………………………………………… 7PHC Balanced Scorecard Online ……………………………………………………………………………… 7Report Content ………………………………………………………………………………………………… 8Implementation of the “Virtual Single Site” ………………………………………………………………… 9Next Steps …………………………………………………………………………………………………… 9

PHC’s Strategic Directions:

1 Lead Through Exceptional Care, Service, Teaching and Research …………………………… 10

2 Live Our Mission ……………………………………………………….…………………………. 26

3 Promote Partnerships …………………………………………………………………………… 28

4 Engage and Develop Our People ……………………………………………………………… 30

5 Foster a Culture of Innovation and Improvement ……………………………………………… 33

Appendix A – PHC Accountability & Performance Improvement Framework …….……………. 34

Appendix B – Dimensions of Quality Matrix ………………………………………………….…… 35

Appendix C – Technical Notes ………………………………………………………………….……37

Performance Summary

2 PHC Annual Performance Report 09/10 Prepared by Administrative Decision Support

Status Indicator Name Comments

Page Ref.

Lead

Thr

ough

Exc

epti

onal

Car

e, S

ervi

ce, T

each

ing

and

Rese

arch

1.1. COPD readmission rate Rate is stable. Target is being met in most fiscal periods over the past

two years, but not in most recent periods. 10

1.2. In-hospital mortality rate for community-acquired pneumonia

Rate is stable. Rate is within the comparator range. 10

1.3. % ST-elevation myocardial infarction patients with door to balloon time less than 90 minutes

Rate has improved. Target is being met. 11

1.4. Aspirin administration rate for AMI and suspected AMI Rate is unstable. Target is being met. 11

1.5. Prevalence of residents with little or no activities Rate is stable. Target is being met. 12

1.6. Incidence of residents who walk as well or better than previous assessment

Rate is stable. Target is not being met; gap between rate and target is not significant. 12

1.7. Median CD4 count for HIV/AIDS Rate has shifted in the desired direction. Target is being met. 13

1.8. Unplanned readmission rate for mental health and addictions

Rate is unstable. Target is not being met in majority of last fiscal year. 13

1.9. Arteriovenous fistula rate for those receiving incident hemodialysis

Rate is stable. Target is not being met; gap between rate and target is not significant. 14

1.10. Rate of receipt of adequate hemodialysis Rate is stable. Target is being met. 14

1.11. % of patients with at least one adverse event Rate is improving. Target is not being met; gap between rate and target

is significant. 15

1.12. In-hospital infection/colonization rate There are insufficient data for indicator status assignment. 16

1.13. Hand hygiene compliance rate Rate is stable. Target is not being met; gap between rate and target is

significant. 16

1.14. HSMR (Hospital Standardized Mortality Ratio) Rate is unstable. Target is not being met; gap between rate and target is

not significant. 17

1.15. In-hospital deaths per 100 patients in CMGs with less than 1% mortality

Rate is stable. Target is being met. 17

1.16. In-hospital fracture rate per 1,000 patients aged 65 years and older

Rate is unstable. Target is being met for the fiscal year but not in the most recent quarter. 18

1.17. Influenza immunization rate for residents Rate is stable. Target is being met. 19

1.18. Influenza immunization rate for staff Rate for acute care staff has improved. Rate for residential care staff has

worsened. Neither target is being met. 19

1.19. % oncology surgery patients receiving surgery within targeted wait times

Rate has shifted in the undesired direction. Target is not being met; gap between rate and target is significant. 20

1.20. % ALC census days Rate has shifted in the undesired direction. Target is not being met; gap

between rate and target is significant. 20

1.21. Proportion of ED patients seen by provider within targets Rates for both CTAS 2 and CTAS 3 have shifted in the desired direction.

Neither target is being met; gaps between rates and targets are significant.

21

1.22. % of admitted patients leaving ED within 10 hours of triage

Rate is stable. Target is not being met; gap between rate and target is significant 21

1.23. % acute LOS (length of stay) compared to ELOS (expected length of stay)

Rate is unstable. Target is not being met and action point has been exceeded in most of the last year. 22

1.24. Cost per weighted case There are insufficient data to comment on trend and assign a status

indicator. 22

1.25. Cumulative net surplus (deficit) Target has been met. 23

1.26. Administrative and support costs as % of total expenses Rate is stable. PHC is outperforming the comparator. 23

1.27. % sick hours Target is not being met; gap between rate and target is not significant. 24

1.28. % overtime hours Rate has improved. Target is not being met; gap between rate and target

is not significant. 24

1.29. Productive nursing hours per patient day (RN, LPN) Rate is stable and close to budget.

25

Performance Summary


Status Indicator Name Comments

Page Ref.

Live

Our

M

issi

on

2.1. % positive responses to survey items related to Spirituality Target is not being met in most recent survey year; gap between rate and target is significant. 26

2.2. % positive responses to survey items related to Integrity Target is not being met in most recent survey year; gap between rate and

target is not significant. 26

2.3. % positive responses to survey items related to Trust Target is not being met in most recent survey year; gap between rate and


2.4. % positive responses to survey items related to Respect Target is not being met in most recent survey year; gap between rate and


Prom

ote

Part

ners

hips

3.1. Resident family overall quality rate Rate has not changed over previous survey year. Target is met in most

recent survey year. 28

3.2. ED patient satisfaction Rates for SPH and MSJ are stable and on par with comparator.

29

3.3. Acute inpatient satisfaction rate Rate has performed on par with comparator.

29

Enga

ge a

nd D

evel

op

Our

Peo

ple

4.1. Overall engagement rate Target is not being met in most recent survey year; gap between rate and


4.2. Difficult to fill vacancy rate Rates for both nurses and Allied Health have improved. Target is being

met for Allied Health but not for nurses; gap between nurses’ rate and target is not significant.

30

4.3. External turnover rate (regular employees) There are insufficient data for indicator status assignment.

31

4.4. WSBC MSI (musculoskeletal injury) incidence rate for direct care areas

Rate has improved. Target is not being met; gap between rate and target is not significant. 32

4.5. WSBC experience rating adjustment Discount to the WCB base rate was achieved for both acute and long

term care rate units. 32

Fost

er a

Cul

ture

of

Inno

vati

on a

nd

Impr

ovem

ent

5.1. Total annual research funding Funding has increased over the previous fiscal year.

33

5.2. Number of invention disclosures The number of invention disclosures has decreased over the previous fiscal year.

33

Indicator status legend (refer to page 9 for status assignment rules): Continue to monitor Review required Action required Not available

A Day in the Life of PHC


On an average weekday: 62 patients are admitted to an acute inpatient bed 2 patients are admitted to an acute rehabilitation bed 5 babies are born 1 resident moves into one of our residential care homes 271 people visit our EDs, 36 of whom are eventually admitted to hospital as an inpatient 14,432 examinations or procedures are conducted 836 visits are made to our clinics 69 patients go home or are transferred from our acute inpatient sites 2 patients pass away at our acute inpatient sites 2 patients go home or are transferred from our acute rehabilitation site 5 babies go home 1 resident passes away or moves out of one of our residential care homes At midnight:

There are 514 patients in an acute inpatient bed; 16 are in intensive care, 11 are on the palliative care unit There are 64 patients in an acute rehabilitation bed There are 12 newborns There are 680 residents in our residential care homes

97 people have major surgery in one of our main ORs or procedure rooms; 61 have major surgery on an outpatient basis and 36 on an inpatient basis

Notes: The above data were compiled by calculating the average daily volumes occurring in FY 09/10. Various data sources were used, including:

Access Manager (AM) Inpatient Admission, Census and Discharge Cubes PHC Revenue & Expense Reports Workload Drilldown Report (Financial Analysis) ORMIS (non-statutory holiday weekdays only)

Background


Introduction This document is intended to provide a broad view of organizational performance with an emphasis on the performance for the fiscal year 2009/2010.

Balanced Scorecard The balanced scorecard provides a comprehensive framework for evaluating the overall performance of an organization by including both financial and non-financial perspectives. Traditionally, the measure of the success of organizations has been based on financial performance without consideration of performance measures relative to the organization’s ability to live its mission or achieve its strategic, non-financial goals. Originally designed for use in the private sector, the use of the balanced scorecard by health care organizations is increasing due to its relevance in managing the many different aspects of performance within the health care setting.

A balanced scorecard measures organizational performance from four different perspectives: the financial, the customer, internal business processes, and learning and growth. The traditional four-perspective approach to the balanced scorecard has been adapted to better align with PHC’s six Strategic Directions for 2009-2012:

1 Live our Mission 2 Lead through exceptional care, service, teaching and research 3 Engage and develop our people 4 Foster a culture of innovation and improvement 5 Promote partnerships 6 Advance our leadership in health care

The new Strategic Directions will inform any future development of the corporate Balanced Scorecard.

PHC Balanced Scorecard Renewal As a result of the release of PHC Strategic Directions 2009-2012: Innovations, Solutions and Exceptional Care for British Columbians in February, 2009, the BSC Renewal Project was launched to realign the corporate BSC indicators to the new strategic directions. Other objectives of the Renewal project included ensuring the relevance and timeliness of the indicators as well as producing a scorecard that was more focused while including a mix of outcome, process and balancing measures.

Background


Selection of PHC Performance Indicators The selection of the performance indicators presented in this report is the result of the efforts of numerous groups within PHC and are approved by PHC senior leadership. The process of renewing the Balanced Scorecard involved repeated discussions with leaders and directors to review the existing indicators for specificity, relevance, actionability, and timeliness. Where new indicators were proposed, work was also done with leaders, directors and content experts to identify high risk and high volume areas of the organization, determine the most appropriate performance indicator to monitor, and identify data sources for the new indicators. Additional indicators have been adopted from both the Ministry of Health Services and Vancouver Coastal Health (VCH). The overarching principles that guide the selection of indicators are as follows:

1. PHC performance indicators reflect the unique mission, vision, and values of this organization 2. PHC performance indicators meet the following criteria:

Promote improvement Are simple and relevant to PHC priorities, goals, and initiatives Are as specific as possible (with reference to location, time frame, patient group, etc.) Reflect a mixture of process, outcome and balancing measures The data required to construct the indicator are readily available and reliable

3. PHC performance indicators will evolve over time with learning, the finalization of organizational strategic directions and goals, as well as the ongoing improvement of PHC’s information systems

4. PHC performance indicators are coordinated with those of the Ministry of Health Services and VCH Clinical indicators for PHC are intended to measure the quality of clinical care at the corporate level with particular emphasis on the six populations of emphasis as identified by the Strategic Directions Group:

People with cardio-pulmonary risks and illnesses People with mental illnesses People with specialized needs in aging People with renal risks and illnesses People with HIV/AIDS Medically and socially complex population

The aim is also to select a set of indicators that collectively addresses the following dimensions of quality: effectiveness, safety, timeliness, patient-centredness, and efficiency. Appendix B - Dimensions of quality matrix (page 35) lists the selected indicators and the dimension of quality each indicator addresses.

Indicator Limitations The selection of indicators is limited by the availability and quality of data currently collected by existing information systems, and thus the indicators presented here are not necessarily the best indicators of organizational performance. Comments related to data limitations for specific indicators are found in Appendix C – Technical notes (page 37).

PHC Balanced Scorecard Online The online balanced scorecard is a tool that enables leaders and other stakeholders to monitor the performance of the corporate Balanced Scorecard (BSC) indicators, which are updated every fiscal period, from their desktops via the PHC intranet. Following the creation of the original online Balanced Scorecard (Version 1.0) in 2004 and the subsequent redevelopment of the new online Balanced Scorecard (Version 2.0) in February, 2009, PHC’s online balanced scorecard has once again been updated to include the new indicators identified in the BSC Renewal Project. Version 3.0 of the online Balanced Scorecard launched on May 14, 2010. For technical reasons, the indicator numbering used in this report is slightly different to that found in the online Balanced Scorecard.

Background


Report Content This report is presented in five sections, each corresponding to one of PHC’s Strategic Directions. Within each section, the following information for each indicator is presented: Indicator definition – a description of the indicator (for details regarding the method of calculation and inclusion/exclusion criteria for each indicator, refer to Appendix C – Technical notes) Indicator specifications – additional information pertaining to the indicator (refer to following section for an explanation) Run chart – the data for the indicator plotted over time (refer to following section for an explanation of run charts) Analysis – an interpretation of the indicator results Next steps – a summary of the proposed follow-up actions or actions in progress for the indicator

Indicator Specifications The following table provides an explanation of the specifications that are provided for each indicator.

Specification Description Type PHC The indicator is unique to PHC

PHC = VCH The indicator is also included in the VCH Balanced Scorecard and is defined in the same way

PHC ≠ VCH The indicator is also included in the VCH Balanced Scorecard but defined differently Report Frequency The unit of reporting (e.g. fiscal period, calendar month) Preferred Trend A decrease in the level of performance is the desired trend for the indicator

An increase in the level of performance is the desired trend for the indicator A stable trend is desired for the indicator Target The desired level of performance for the indicator Comparator The level of performance for a comparison organization/entity Summary Symbol See Indicator status legend on page 9

Run Charts Wherever possible and relevant, the data in this report have been presented as run charts. A run chart is a performance improvement tool used to understand variation in a process. Run chart theory is based on the premise that two kinds of variation exist: the kind that is inherent in the process (common-cause variation) and the kind that is caused by some

external influence (special cause variation). Run charts aid in the detection of special causes variation. The four following tests can be applied to a chart to determine the presence of a special cause (Note: As a general rule of thumb, the minimum number of useful observations (i.e., data points) that are needed to construct a run chart is 15):

Test 1: Too many/too few runs – A run is one or more consecutive data points on the same side of the center line. Depending on the number of data points available, there is a range of the number of runs one would expect to see from a common cause process. If there are too few or too many runs than expected, this suggests the presence of special causes of variation. For a chart with 15 useful observations the number of runs one expects to see is 4 to 12.

Time Period

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Rat

e

0%

20%

40%

60%

80%

100%

Rate Avg

special cause - a shift

Background


Test 2: A trend – A trend has occurred when there is an unusually long series of consecutive increases or decreases in the data. For a dataset with 20 or less useful observations, what constitutes an “unusually long series” is 6 or more data points all increasing or decreasing, and for a dataset with more than 20 useful observations, 7 or more data points. Test 3: A shift – A shift has occurred in the process when a run contains too many data points. 7 or more data points in a run is considered “too many” for a dataset with less than 20 useful observations, and 8 or more data points in a run for 20 or more useful observations. Test 4: A pattern – When 14 or more points form a zig-zag pattern.

When any of the above test conditions are met, this suggests the presence of a special cause, and therefore requires further investigation into the nature of the special cause. Chart Colour‐Coding This report adheres to the following colour-coding conventions for most run charts presented:

Indicator Status Legend A status symbol is assigned to each indicator based on the following rules:

Continue to monitor Target is being met

OR, if no target is defined, PHC is outperforming comparator OR, if no comparator is defined, a shift is observed in the desired direction

Review required

Target is not being met (gap between actual and target is not “significant”) OR if no target is defined, comparator is on a par with or is outperforming PHC (gap between actual and comparator is not “significant”)

OR, if no comparator is defined, the indicator is stable or a shift is observed in the undesired direction

Action required

Action point is exceeded OR, if no action point is defined, target is not being met (gap between actual and target is “significant”)

OR, if no target is defined, comparator is outperforming PHC (gap between actual and comparator is “significant”)

Not available Neither a target nor comparator is defined and there are insufficient data for trend analysis

Implementation of the “Virtual Single Site” On February 9, 2009, PHC was reconceptualized as a “virtual single site”, meaning that PHC’s acute sites (SPH, MSJ, and HFH) and their associated activity are treated by information systems and Health Records as if they are part of a single acute care facility. Consequently, transfers between acute care sites no longer constitute a discharge from the sending acute care site and an admission to the receiving acute care site, functioning very much like transfers from one unit to another.

Next Steps Although the BSC Renewal Project has been completed, a process of continual monitoring will ensue to ensure the utility of the new indicators and the extent to which they meet PHC’s requirements.

PHC actual

PHC average

Target

Action point

Comparator

Lead Through Exceptional Care, Service, Teaching and Research


1

1.1. COPD readmission rate Definition The proportion of total inpatients with a most responsible diagnosis of chronic obstructive pulmonary disease (COPD) who had anunplanned readmission to the same facility within 28 days.

Type Report

Frequency Preferred

Trend Target Comparator Summary Symbol

Analysis The average COPD readmission rate is 11.8% for FY09/10 and 13.3%for the whole time period shown, which meets the target of 14%. A shiftin the desired direction was observed between P8-08/09 and P5-09/10.PHC has outperformed VCH in the majority of the last 13 fiscal periods. Next Steps Revisions to the COPD pathway, referral process for rehabilitation andordering of spirometry is in the process of being finalized. Education ofthese processes is underway by the COPD educator to the care teamsin Emergency, Medicine and Respirology. Additional funding wasapproved to extend the LMIIF funding for additional spirometry,rehabilitation and patient education for two months. A trial of the COPDpathway will be initiated at MSJ on July 26th. The pathway will then berolled out to SPH in the fall of 2010.

PHC Fiscal Period 14.1% VCH

Fiscal Period

07/0

8-01

07/0

8-02

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

8-11

07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

COPD

read

miss

ion

rate

0%

10%

20%

30%

PHC PHC Avg Target VCH

1.2. In‐hospital mortality rate for community‐acquired pneumonia Definition The proportion of inpatients with a most responsible diagnosis of community-acquired pneumonia who died in hospital.

Type Report

Frequency Preferred


Analysis The in-hospital mortality rate for community acquired pneumonia is8.0% for the entire period shown and 5.9% FY 09/10. Both are withinthe in-hospital mortality rate of 12% found in the literature. Next Steps Continue to monitor the progress of this indicator.

PHC Fiscal Period - 12%

Fiscal Period

07/0

8-01

07/0

8-02

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

8-11

07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

In-h

ospi

tal m

orta

lity r

ate

0%

5%

10%

15%

20%

25%

30%

PHC PHC Avg Literature review

Medically/Socially Complex

Medically/Socially Complex



11.3. % of ST‐elevation myocardial infarction patients with door‐to‐

balloon time less than 90 minutes

Definition The number of patients with a most responsible diagnosis of ST-elevation myocardial infarction (STEMI), with a door to balloon time(time from hospital arrival to PCI-percutaneous coronary intervention) less than the target of 90 minutes as a proportion of the totalnumber of patients with a most responsible diagnosis of STEMI.

Analysis The proportion of STEMI patients meeting the target door to balloontime of 90 minutes or less has increased since Q1 of 09/10. Both Q4and FY-09/10 are above the target at 91% and 78%, respectively. Next Steps Continue to monitor this indicator and provide Heart CatheterizationLab and Emergency teams with timely feedback (semi-automated"report card"). Work with Emergency staff to explore improvements forwalk-in patients. Work with regional partners to expand direct PCIservice to include patients presenting at other hospitals within VCH.

Type

Report Frequency

Preferred Trend Target Comparator

Summary Symbol

PHC Fiscal Quarter 75% -

Fiscal Quarter

09/1

0-Q

1

09/1

0-Q

2

09/1

0-Q

3

09/1

0-Q

4

% S

T-ele

vatio

n MI

pat

ients

0%

20%

40%

60%

80%

100%

PHC PHC Avg Target

1.4. Aspirin administration rate for AMI and suspected AMI Definition The proportion of inpatients with a most responsible, Type 1, or Type 2 diagnosis of acute myocardial infarction (AMI) or suspectedAMI who received a scheduled regular dose of aspirin during hospitalization.

Analysis The aspirin administration rate for AMI and suspected AMI was stableup to P7-09/10, but fell below the target between P9 and P11 as aresult of low rates in the Medicine program. However, the average ratefor FY 09/10 meets the target at 91.2%. Next Steps Continue to monitor the progress of this indicator.

Type

Report Frequency


Summary Symbol

PHC Fiscal Period 90% -

Fiscal Period

07/0

8-01

07/0

8-02

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

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07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

Aspi

rin ad

min

istra

tion

rate

70%

75%

80%

85%

90%

95%

100%

PHC PHC Avg Target

People with Cardio-Pulmonary

Risks & Illnesses

People with Cardio-Pulmonary

Risks & Illnesses



1

1.5. Prevalence of residents with little or no activities Definition The number of residents with little or no activity on the target assessment as a proportion of all residents with a target assessment.

Type Report

Frequency Preferred


Analysis The percentage of residents with little or no activities has been stable atan average of 38.7% Next Steps The residential staffing model was designed to encourage staff to formrelationships with residents, engage residents in small informalactivities, to create interesting, homelike environments and to assistwith larger activities planned with Rehab support. Work is continuallybeing done to look for ways to facilitate those activities.


09/10-Q1 09/10-Q2 09/10-Q3 09/10-Q4

% w

ith lit

tle o

r no

activ

ities

0%

10%

20%

30%

40%

50%

60%

Fiscal QuarterPHC AvgPHC Target


Definition The proportion of residents whose walking is the same or better in the most recent assessment, compared to the assessment done inthe previous quarter.

Type Report

Frequency Preferred


Analysis The percentage of residents walking as well or better than theirprevious assessment has been stable for FY 09/10 at 93.5%. Next Steps Implement two interprofessional best practice guidelines co-developedwith VCH: least restraint and fall prevention. Ensure compliance withresidential required operational practices: fall prevention and educatingresidents/family regarding their role in promoting safety.


09/10-Q2 09/10-Q3 09/10-Q4

% w

ith lit

tle o

r no

activ

ities

0%

20%

40%

60%

80%

100%

Fiscal QuarterPHC AvgPHC Target

People with Specialized Needs in Aging

People with Specialized Needs in Aging



11.7. Median CD4 count for HIV/AIDS Definition The median CD4 count of active patients in the IDC clinic.

Analysis The median CD4 count has consistently been above the target of 350cells/mm3 since 05/06-Q4. The average of the median CD4 counts ofeach quarter in FY 09/10 is 426 cells/mm3. Next Steps Assertive engagement of complex patients to commence and adhere toHighly Active Antiretroviral Therapy (HAART), nurse led follow up of allpatients who default appointments or stop HAART aftercommencement, 3 monthly blood work on all registered, active patientson HAART to ensure CD4 remains within therapeutic guidelines, andreferral of 10C patients to IDC for follow up and HAARTcommencement/assertive engagement on discharge to improveretention in care.

Type

Report Frequency


Summary Symbol

PHC Fiscal Quarter 350 cells/mm3 -

Fiscal Quarter

05/0

6-Q

1

05/0

6-Q

2

05/0

6-Q

3

05/0

6-Q

4

06/0

7-Q

1

06/0

7-Q

2

06/0

7-Q

3

06/0

7-Q

4

07/0

8-Q

1

07/0

8-Q

2

07/0

8-Q

3

07/0

8-Q

4

08/0

9-Q

1

08/0

9-Q

2

08/0

9-Q

3

08/0

9-Q

4

09/1

0-Q

1

09/1

0-Q

2

09/1

0-Q

3

09/1

0-Q

4

Medi

an C

D4 co

unt (

cells

/mm

3 )

0

100

200

300

400

500

PHC PHC Avg Target

1.8. Unplanned readmission rate for mental health and addictions Definition The proportion of total inpatients with a most responsible mental health or addictions diagnosis and between the ages of 15 and 64years who were readmitted to the same facility within 28 days.

Analysis The average unplanned readmission rate for mental health andaddictions for FY09/10 is 12%, which is above the target of 11%.However the average since FY 07/08 meets the target at 10.5%. VCHhas been outperforming PHC in the majority of the last 24 periods. Next Steps A regional Lean project will examine the processes associated withpsychiatric inpatient visits. The initial planning session took place inJune, 2010. Continue to monitor the progress of this indicator.

Type

Report Frequency


Summary Symbol

PHC Fiscal Period 11% VCH

Fiscal Period

07/0

8-01

07/0

8-02

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

8-11

07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

% ca

ses t

hat w

ere r

eadm

issio

ns

0%

5%

10%

15%

20%

25%


People with HIV/AIDS

People with Mental Illnesses



1

1.9. Arteriovenous fistula rate for those receiving incident hemodialysis

Definition The number of chronic hemodialysis patients who start hemodialysis and the first access used is arteriovenous fistula (AVF), as aproportion of all patients started on hemodialysis.

Type Report

Frequency Preferred


Analysis The average arteriovenous fistula (AVF) rate since Q3 of 07/08 is23.8%, which is below the target of 30%. The average SPH AVF ratehas exceeded the BC Provincial rate since 2008. BC Provincial ratesfor Oct 08- Mar 09, Apr - Sep 09, Oct 09 - Mar 10 were 12%, 17%, and13%, respectively whereas corresponding rates for SPH across sameperiods were 19%, 24% and 27%, respectively. Next Steps To prevent further increases in the AVF rate, multidisciplinary roundswith the Link nurse and with the Kidney Function Clinic staff have beenestablished to review patients with glomerular filtration rate (GFR) < 15ml/min or GFR > 15 ml/min but rapid deterioration (greater than 5ml/min/year). This will expedite referral of patients to the clinic for fistulacreation. In addition, data showing that wait time to the operating room(OR) has increased from 24 days in 2005 to 100 days as of May, 2010has been presented to the SPH operations leader for surgical bookingsand to the BC Provincial Renal Agency. They are currently working outstrategies to increase OR capacity. 5% annual increase for the SPHincident AVF rate has been targeted.

PHC Calendar Quarter 30% VGH

Calendar Quarter

2007

-Q3

2007

-Q4

2008

-Q1

2008

-Q2

2008

-Q3

2008

-Q4

2009

-Q1

2009

-Q2

2009

-Q3

2009

-Q4

AVF

rate

(%)

0%

10%

20%

30%

40%

50%

PHC PHC Avg Target

1.10. Rate of receipt of adequate hemodialysis Definition The proportion of dialysis patients receiving adequate hemodialysis (defined as a percent reduction of urea, or PRU, measurementequal to or above 0.65).

Type Report

Frequency Preferred


Analysis The rate of receipt of adequate hemodialysis has been above theaverage in most periods since P6-08/09. The average rate for FY09/10is 93% and the target of 85% has consistently been met since P1-07/08. Factors contributing to the improvement in performance include:the addition of an evening clinic, the implementation of a more effectivedialyzer, and the assignment of a consistent physician for morning andafternoon dialysis shifts to provide better continuity of care. Anadditional nurse practitioner is instrumental in ensuring thorough roundsand follow-up. Next Steps Continue to monitor the progress of this indicator.


Fiscal Period

07/0

8-01

07/0

8-02

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

8-11

07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

% ca

ses w

ith ad

equa

te d

ialys

is

70%

75%

80%

85%

90%

95%

100%

PHC PHC Avg Target

People with Renal Risks & Illnesses

People with Renal Risks & Illnesses



11.11. % of patients with at least one adverse event Definition The number of patients with at least one adverse event (harm) as a proportion of the number of charts audits performed using the IHIGlobal Trigger Tool (GTT).

Analysis The average percentage of patients with at least one adverse event isstable with an average of 45% from October, 2006 to March, 2010. Thisdoes not meet the target of 30%. The top five adverse event triggersidentified in 2009 were: any procedure complication, infections of anykind (the most common of which was urinary tract infection), oversedation/hypotension, abrupt medication stop and other medicationmodule triggers. Next Steps Continue with implementation of the Nursing Care Standard -Management of Urinary Catheters for the Prevention of Urinary TractInfection (UTI). Work with provincial GTT Community of Practice tobetter define the categories of adverse events. Continue to analyzedata to identify future patient safety projects.

Type

Report Frequency


Summary Symbol

PHC Calendar Month 30% -

Calendar Month

Oct

06

Nov

06

Dec

06

Jan

07Fe

b 07

Mar

07

Apr 0

7M

ay 0

7Ju

n 07

Jul 0

7Au

g 07

Sep

07O

ct 0

7N

ov 0

7D

ec 0

7Ja

n 08

Feb

08M

ar 0

8Ap

r 08

May

08

Jun

08Ju

l 08

Aug

08Se

p 08

Oct

08

Nov

08

Dec

08

Jan

09Fe

b 09

Mar

09

Apr 0

9M

ay 0

9Ju

n 09

Jul 0

9Au

g 09

Sep

09O

ct 0

9N

ov 0

9D

ec 0

9Ja

n 10

Feb

10M

ar 1

0

% o

f pat

ients

with

at le

ast o

ne ad

vers

e eve

nt

0%

20%

40%

60%

80%

100%

PHC PHC Avg Target

Safety



1

1.12. In‐hospital infection/colonization rate Definition The number of laboratory-confirmed cases from specimens indicative of colonization or infection in cases admitted for greater or equalto 72 hours in a PHC facility or admitted to a PHC facility within the preceding four weeks, per 1000 acute inpatient census days.

Type Report

Frequency Preferred


Analysis The incidence rate of PHC-associated MRSA was 1.0 cases/1000patient days in 08/09. This is a decrease of 10% from 07/08 and 51%from 02/03. MRSA rates have decreased despite ongoing communitytransmission and the introduction of highly transmissible community-associated strains to the hospital setting. The incidence rate of PHC-associated VRE is 2.1 cases/1000 days. This is higher than the 07/08rate of 1.7 but lower than previous years. The increase can be partiallyexplained by physical construction and organizational restructuring atMSJ. Overall, VRE incidence rates have decreased by 23% since06/07. The incidence rate of PHC-associated Clostridium DifficileInfection (CDI) in 08/09 is 1.0 cases/1000 patient days. Despite theintroduction of a hypervirulent strain of CDI to PHC, the incidence rateremained stable. Next Steps Continue to monitor the progress of PHC-associated infections/colonization rate. Increase awareness of the link between hand hygieneand PHC-associated MRSA, VRE, and CDI by promoting the unitfeedback boards. Use unit feedback boards and link nurses to improveeducation and awareness of staff on units regarding the link betweenhand hygiene and in-hospital infection/colonization.

PHC Fiscal Year - -

Fiscal Year

02/0

3

03/0

4

04/0

5

05/0

6

06/0

7

07/0

8

08/0

9PHC-

asso

ciate

d ca

ses/1

000 p

atien

t-day

s

0.0

0.5

1.0

1.5

2.0

2.5

3.0

MRSAAvg (MRSA) Avg (VRE)

VRE CDIAvg (CDI)

1.13. Hand hygiene compliance rate Definition The number of compliant hand hygiene events as a proportion of the number of hand hygiene opportunities.

Type Report

Frequency Preferred


Analysis Infection Prevention and Control commenced quarterly hand hygieneaudits on acute care units at SPH and MSJ and rehab units at HFH inDecember, 2008 and in the EDs at SPH and MSJ in April, 2009. Theresults have been stable at an average of 45.9% for FY 09/10. Next Steps A mandatory online hand hygiene education module is in place for newmedical staff and medical staff seeking reappointment. An onlineeducation module for nursing and Allied Health was initiated by IPAC inMay, 2010. As of June 22, 2010, 228 e-modules have been completed.Mandatory annual compliance is being considered. Unit feedbackboards were introduced at the acute units in December, 2009. Theseboards show the unit’s hand hygiene compliance results compared tothe overall PHC score plus monthly cases of antibiotic resistantorganisms that are specifically attributed to the unit. As well, the linknurse program has been reinitiated, where an infection-control-trainednurse in each unit serves as a link between the nurses on the unit andIPAC. The Ask Me campaign has recently been launched at PHC,which engages patients to ask their health care worker if they havecleaned their hands.


08/09-Q3 08/09-Q4 09/10-Q1 09/10-Q2 09/10-Q3 09/10-Q4

Com

plian

ce ra

te

0%

20%

40%

60%

80%

100%

Fiscal Quarter

PHC AvgPHC Target

Safety

Safety



11.14. HSMR (Hospital Standardized Mortality Ratio) Definition The ratio of the actual number of acute in-hospital deaths to the expected number of in-hospital deaths for conditions accounting for80% of inpatient mortality nationally.

Analysis The preliminary FY 09/10 HSMR is 95.2, which indicates that PHC’sactual number of deaths is lower than the expected number of deaths.However, the target ratio of 75 is not met. The Q3-09/10 value is higherthan what has been previously seen. However, the increase in the Q3HSMR is not statistically significant. The Q4-09/10 HSMR returns toaverage levels. *Note: The 2009/2010 HSMR value was calculated using the monthlyeHSMR report and CIHI’s quarterly tool for Q3 and Q4 values, sincefinal results from CIHI are not yet available. Next Steps Continue implementation of the Safer Healthcare Now! Initiatives, whichinclude: improved care for acute myocardial infarction, prevention ofcentral line-associated bloodstream infections, implementation ofmedication reconciliation, implementation of Rapid Response Teams,prevention of surgical site infections, and prevention of ventilator-associated pneumonia.

Type

Report Frequency


Summary Symbol

PHC Calendar Quarter 75 National (2004)

Calendar Quarter

04

/05-

Q1

04/0

5-Q

204

/05-

Q3

04/0

5-Q

405

/06-

Q1

05/0

6-Q

205

/06-

Q3

05/0

6-Q

406

/07-

Q1

06/0

7-Q

206

/07-

Q3

06/0

7-Q

407

/08-

Q1

07/0

8-Q

207

/08-

Q3

07/0

8-Q

408

/09-

Q1

08/0

9-Q

208

/09-

Q3

08/0

9-Q

409

/10-

Q1

09/1

0-Q

209

/10-

Q3

09/1

0-Q

4

HSMR

60

80

100

120

140

60

80

100

120

140

FY HSMRNational

Qtr HSMRQtr HSMRFY LCL & UCLQtr LCL & UCL

Target

Deaths/2000 patients

1.15. In‐hospital deaths per 100 patients in CMGs with less than 1% mortality

Definition The number of in-hospital deaths per 100 patients in "low mortality" case mix groups (CMGs). "Low mortality" CMGs are defined asthose CMGs with less than 1% mortality based on national Discharge Abstract Database data.

Analysis The average number of in-hospital deaths in low-mortality CMGs for FY09/10 is 0.12 per 100 patients. The low numbers, most likely the resultof a new palliative care coding standard introduced in FY08/09, havecontinued. The target of 0.75 deaths per 100 cases is consistentlybeing met. PHC has been outperforming VCH in the majority of the last13 periods. Next Steps Continue to monitor the progress of this indicator.

Type

Report Frequency


Summary Symbol

PHC Fiscal Period 0.75 VCH

Fiscal Period

0708

-01

0708

-02

0708

-03

0708

-04

0708

-05

0708

-06

0708

-07

0708

-08

0708

-09

0708

-10

0708

-11

0708

-12

0708

-13

0809

-01

0809

-02

0809

-03

0809

-04

0809

-05

0809

-06

0809

-07

0809

-08

0809

-09

0809

-10

0809

-11

0809

-12

0809

-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

Deat

hs p

er 10

0 low

-mor

talit

y cas

es

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4


Safety

Safety



1

1.16. In‐hospital fracture rate per 1,000 patients aged 65 years and older

Definition The number of patients with at least one in-hospital fracture per 1,000 patients aged 65 years and older. Excludes fractures of thebone following orthopaedic implant and minor fractures.

Type Report

Frequency Preferred


Analysis For FY 09/10, there has been an average of 1.8 in-hospital fracturesper 1,000 patients aged 65 years or older. This is a decrease from therate of 2.5 experienced in the previous fiscal year. The target rate of 2.0is being met. Next Steps Following the last review, a plan was developed to support staff in fallsprevention at HFH. As well, the Clinical Nurse Educators (CNE) andClinical Nurse Leaders (CNL) of 9CD initiated a flagging process toidentify all patients at risk of fall and patients who have fallen. This hasbeen successful in reducing the number of falls. Reviews of fracturescontinue to be performed. Meetings have been set up with operationsleaders (OLs) to talk about the data and plan for sharing the results withstaff. The Falls Injury Prevention & Management (FIPM) Team isfollowing up with the OLs, CNEs, and CNLs for units with fractures toensure that the FIPM tools (including SAFESTEP, Falls RiskAssessment, Quick Mobility screen, and trigger questions) andHovermatts/Jacks are being used, all patients are following the ElderCare Bowel Protocol, and increased frequency of assisted toileting isinstituted. Several versions of a simpler falls screen are being trialed aspart of the new admission biography.

PHC Fiscal Quarter 2 VCH

Fiscal Quarter

07/0

8-Q

1

07/0

8-Q

2

07/0

8-Q

3

07/0

8-Q

4

08/0

9-Q

1

08/0

9-Q

2

08/0

9-Q

3

08/0

9-Q

4

09/1

0-Q

1

09/1

0-Q

2

09/1

0-Q

3

09/1

0-Q

4

In-h

ospi

tal f

ract

ure r

ate

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0


Safety



11.17 Influenza immunization rate for residents Definition The proportion of all residents who received an influenza vaccination.

Analysis The influenza immunization rate for residents for FY09/10 was 92.1%,which meets the target of 90%. The rate has been relatively stable overthe time period shown. The rate for VCH was 91% for FY09/10. Next Steps Continue to monitor the progress of this indicator.

Type

Report Frequency Preferred Trend Target Comparator

Summary Symbol

PHC Fiscal Year 90% VCH

Imm

uniza

tion

rate

for r

esid

ents

0%

20%

40%

60%

80%

100%

PHC VCH

Fiscal Year05/06 06/07

Target

07/08 08/09 09/10

1.18 Influenza immunization rate for staff Definition The proportion of all full-time and part-time staff working in acute and residential care who received an influenza vaccination during theflu season.

Analysis The influenza immunization rate for staff for FY 09/10 was 51.7% foracute care and 59.1% for residential care. For acute care, the rate hasbeen improving since 06/07. There has been a decrease in theresidential care rate compared with the previous year. This may berelated to the out of ordinary circumstances surrounding the H1N1immunization campaign. Neither target is being met. VCH saw higherrates than PHC for FY09/10 with rates of 54% for acute care staff and60% for residential care staff. *Note: FY09/10 data includes people who have been immunized foreither influenza or H1N1 or both. Next Steps A committee has been established to work with the Lower MainlandConsolidation Occupational Health and Safety team to increase therate. An advertising campaign incorporating key messages derivedfrom a staff survey following the 09/10 influenza season will belaunched.

Type


Summary Symbol

PHC Fiscal Year Acute care: 60%Res care: 80% VCH

Imm

uniza

tion

rate

0%

20%

40%

60%

80%

100%

PHC VCH

Fiscal Year

Target

Acute Care Residential Care

06/0706/07 07/08 07/0808/09 08/0909/10 09/10

Safety

Safety



1

1.19. % oncology patients receiving surgery within targeted wait times Definition The proportion of patients who underwent oncological surgery who received surgery within the target wait time of the booking cardreceipt date.

Type Report

Frequency Preferred


Analysis The average percent of oncology surgery patients receiving surgerywithin targeted wait times is 66.7% for the whole time period shown and61.7% for FY 09/10. Both are below the target of 90%. A shift in theundesired direction is observed starting P4-09/10. This coincides withan increase in breast biopsies at MSJ. Although highly successful, theBreast Health Clinic has seen increased volumes in the last fewmonths, increasing demand for operating room (OR) time. Next Steps The existing system for flagging oncology cases and attaching wait-time targets is error-prone and under revision. New regional prioritycodes and corresponding wait time targets have been developed toimprove the coding and prioritization of urgent surgeries, includingoncology cases. This data will be incorporated into the surgicalResource Allocation Methodology (RAM), which will allow betterallocation of OR time based on priorities, such as oncology. In addition,PHC is currently negotiating for supplementary funding to expandcurrent operating room capacity, which will increase access to care andreduce current waits. Notably, a significant portion of this capacity willbe dedicated strictly to breast oncology procedures.

PHC Fiscal Period 90% VCH

Fiscal Period

07/0

8-01

07/0

8-02

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

8-11

07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

% w

ait ti

me w

ithin

targ

et

0%

20%

40%

60%

80%

100%


1.20. % ALC census days Definition Proportion of all acute and rehab inpatient census days that are designated as ALC. Includes HFH and excludes newborns.

Type Report

Frequency Preferred


Analysis A shift in the desired direction in % ALC census days ended and a shiftin the undesired direction began in P2-09/10. The average rate for09/10 is 8.3%, and the target of 4.3% is consistently not being met.Bed closures in the region have had an impact on the ability to placesome ALC patients. Overall, Vancouver Health Service Delivery Area(HSDA) has been outperforming PHC over the last 13 fiscal periods. Next Steps Link with PHC residential care sites to identify need for specialty bedsfor difficult to place ALC patients. Medicine MD collaboration with TSTteams to increase understanding of criteria that deem patients ALC,resulting in more timely assessment and designation. Ongoingeducation from TST to acute inpatient areas regarding processes fordetermining ALC to improve PHC’s role in preventing delays. Workwith Vancouver HSDA to ensure equal access to transitional carebeds. Look for opportunities within program areas to streamline accessand flow. Make ALC a part of the teamCare focus.

PHC Fiscal Period 4.3% Vancouver HSDA

Fiscal Period

07/0

8-01

07/0

8-02

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

8-11

07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

% A

LC ce

nsus

day

s

0%

2%

4%

6%

8%

10%

12%

PHC PHC Avg Target Vancouver HSDA

Timeliness

Timeliness



11.21. Proportion of ED patients seen by provider within targets Definition The proportion of Canadian Emergency Department Triage & Acuity Scale (CTAS) level 2 and 3 ED patients seen by a physician,psychiatric CNL, medical resident or medical student within target times of 15 minutes and 30 minutes, respectively.

Analysis For PHC overall, the proportion of ED patients seen by a providerwithin target times is 52.5% for CTAS 2 and 59.2% for CTAS 3 overthe time period shown. Both CTAS 2 and CTAS 3 have seen shifts inthe desired direction. Neither target (95% for CTAS level 2 and 90%for CTAS level 3) is being met. PHC has been outperformingVancouver Acute for both CTAS levels over the last 3 years. Next Steps SPH ED has been trialing the provision of MD coverage at triage for 5hours per day during peak hours to ensure timely access for patients.Evaluation of this initiative is ongoing. An individual physician reportcard is being developed to use in discussions with each MD to assistwith increasing performance.

Type


Summary Symbol

PHC Fiscal Period CTAS 2: 95% CTAS 3: 90% Van Acute

Fiscal Period

07/0

8-01

07/0

8-02

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

8-11

07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

% ca

ses s

een

with

in ta

rget

tim

e

0%

20%

40%

60%

80%

100%

CTAS 3 Target Van AcuteAvgTarget Van AcuteAvgCTAS 2

1.22. % of admitted patients leaving ED within 10 hours of triage Definition The proportion of all patients admitted via SPH ED who leave the ED within 10 hours of triage. Part of Emergency Decongestion Planindicators.

Analysis The percentage of admitted patients leaving the ED within 10 hours oftriage since the Comox unit was declared an inpatient area in P5-08/09 is 55.3%. The target of 80% is not being met in any fiscalperiod. In terms of volume, programs that are contributing most to therate are Medicine and Mental Health. Next Steps Through the Emergency Decongestion Project, focused workcontinues with both Medicine and Mental Health teams to reduce EDwait times. teamCARE Providence was implemented on the MedicineUnits at MSJ in January, 2009, the Geri Psych unit at MSJ in June,2009, SPH 9A in February, 2010 and in the Medicine Program and4NW at SPH at the end of March, 2010. The complete implementationshould help with streamlining processes. Progress chaser roles inboth ED and Medicine are being trialed to improve timely transitions incare from ED to Medicine for admitted patients. In the Mental HealthProgram, planning is underway for an additional 12 Mental Healthbeds with an anticipated opening date of September 1, 2010.

Type


Summary Symbol


Fiscal Period

0708

-01

0708

-02

0708

-03

0708

-04

0708

-05

0708

-06

0708

-07

0708

-08

0708

-09

0708

-10

0708

-11

0708

-12

0708

-13

0809

-01

0809

-02

0809

-03

0809

-04

0809

-05

0809

-06

0809

-07

0809

-08

0809

-09

0809

-10

0809

-11

0809

-12

0809

-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

% w

ait ti

me w

ithin

targ

et

0%

20%

40%

60%

80%

100%


Timeliness

Timeliness



1

1.23. % acute LOS (length of stay) compared to ELOS (expected length of stay) Definition The acute length of stay as compared to the expected length of stay, expressed as a percentage. Includes only typical cases andexcludes newborns, stillbirths, and ALC days. Prior to P12-08/09, HFH cases were also excluded.

Type Report

Frequency Preferred


Analysis The performance of the percent acute LOS compared to ELOS hasdeteriorated since P9-07/08. Prior to this, all data points fell below theaverage. The average rate since P9-07/08 is 101.1%, which does notmeet the target of 95%. The programs that have not met the target inFY 09/10 are: Acute Services, Elder Care, HIV/AIDS, Medicine, andMental Health. VCH has been outperforming PHC over the last 13fiscal periods. Next Steps teamCARE Providence was implemented on the Medicine Units atMSJ in January, 2009, the Geri Psych unit at MSJ in June, 2009, SPH9A in February, 2010, and in the Medicine Program and 4NW at SPHat the end of March, 2010. The remainder of the Mental HealthProgram will be implementing teamCare through September, 2010.teamCARE is a structured rounding process during which all membersmeet to discuss patient needs. The goal of teamCARE is to improvethe quality of care by producing team driven, clearly defined care plans,the progress of which are reviewed daily. teamCARE also strives tomake a parallel process out of care and discharge planning, in order toenhance patient flow. This initiative will also enable teams to capturesystem barriers that impede care and discharge planning. A regionalLean project that will examine the processes associated withpsychiatric inpatient visits has been initiated.

PHC=VCH Fiscal Period 95% VCH

Fiscal Period

07/0

8-01

07/0

8-02

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

8-11

07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

% ac

ute L

OS/E

LOS

80%

85%

90%

95%

100%

105%

110%

115%

PHC PHC Avg Target VCHAction Point

1.24. Cost per weighted case Definition The operating costs for a specific set of functional centres (patient transport, patient food services, inpatient nursing, ambulatory care,and diagnostic and therapeutic services) excluding medical staff compensation, equipment acquisition, building amortization and rent,divided by the total acute inpatient weighted cases.

Type Report

Frequency Preferred


Analysis The cost per weighted case has increased every year since 2004/2005. *Note: Weighted cases used in each year have been grouped to thesame CMG grouping methodology; however, costs are unadjustedfrom year to year. Re-grouping generally results in a decrease ininpatient weighted cases. Next Steps Work has begun jointly with VCHA Finance to implement the reportingof cost per weighted case each fiscal period. Expected completion dateis July, 2010.

PHC ≠ VCH Fiscal Year - -

Fiscal Year

04/0

5

05/0

6

06/0

7

07/0

8

08/0

9

Cost

per

weig

hted

case

($)

$0

$1000

$2000

$3000

$4000

$5000

PHC PHC Avg

Efficiency

Efficiency



11.25. Cumulative net surplus (deficit) Definition The cumulative year-to-date net surplus (deficit) where the net surplus (deficit) is calculated after retirement allowances.

Analysis PHC’s cumulative net surplus as at P13-09/10 is $117,622. VCH isalso in a surplus position as at P13-09/10 with $71,000. Next Steps 2010/11 savings strategies include the Attendance PromotionProgram to reduce sick & overtime; administration & supportReductions; Medical bed closures via length of stay improvements;the Care Delivery Model Redesign project; Lean reviews – e.g.Surgical Day Care (SDC) & Post Anaesthetic Recovery (PAR); theShared Services Organization Non Labour Savings; and savingsthrough the Lower Mainland Consolidation.

Type


Summary Symbol

PHC Fiscal Period Plan VCH

Fiscal Period

07/0

8-01

07/0

8-02

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

8-11

07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

Cum

ulat

ive n

et su

rplu

s (de

ficit)

(in m

illion

s of d

ollar

s)

-40

-30

-20

-10

0

10

20

PHC Target VCH

1.26. Administrative and support costs as % of total expenses Definition The proportion of total expenses incurred for administrative and support services (excludes Information Systems).

Analysis The administrative and support costs as a percent of total expensesfor FY 09/10 is 10.7%.This constitutes an increase of 0.5% from theprevious fiscal year’s rate. The rate of this indicator is stable overtime. PHC has been outperforming VCH. Next Steps Continue to monitor the progress of this indicator.

Type


Summary Symbol

PHC = VCH Fiscal Period - VCH

Fiscal Period

07/0

8-01

07/0

8-02

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

8-11

07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

% ad

min

and

supp

ort c

osts

0%

5%

10%

15%

20%

PHC PHC Avg VCH

Efficiency

Efficiency



1

1.27. % sick hours Definition The number of sick hours expressed as a percentage of productive hours.

Type Report

Frequency Preferred


Analysis The percent sick hours for FY 09/10 is 4.8%, which does not meet the target of 4.3%. There has been no change from the sick hours rate for FY 08/09. The higher numbers in P7 and P8 are likely the result of H1N1. Sick time had a smaller spike upwards in February, 2010 for all Lower Mainland Health Authorities, due to the Olympics. PHC is performing on par with VCH. The new Attendance Promotion Program (APP) began with a mail out of booklets to all staff in March 2010. Next Steps The Executive Director of Human Resources (HR)/Labour Relations (LR) for PHC-PHSA-VCH has joined the Sick Time/Overtime committee. An attendance promotion booklet was sent to staff describing the policy and what is expected of staff in March, 2010. Consolidated HR is now responsible for APP management. An APP analyst will be supporting managers to address employees with high sick time. Meetings will be held with these employees, shop stewards, manager and HR advisor regarding high sick time.

PHC = VCH Fiscal Period 4.3% VCH

Fiscal Period

07/0

8-01

07/0

8-02

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

8-11

07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

% si

ck h

ours

3%

4%

5%

6%

7%


1.28. % overtime hours Definition The proportion of total productive hours that are overtime hours.

Type Report

Frequency Preferred


Analysis The percent overtime (OT) hours for FY 09/10 is 3.2%. This is adecrease from the OT rate of 4.0% in FY 08/09 and is very close to thetarget of 3.1%. A number of programs have achieved relativeimprovements in their OT rate over the previous fiscal year, e.g. AcuteServices (-13%), Cardio-Pulmonary (-19%), Maternity (-36%), Palliative(-33%), Medicine (-26%), Surgery (-14%), HIV/AIDS (-13%) MentalHealth (-34%) and Elder Care (-34%). VCH is consistentlyoutperforming PHC. Next Steps Expectations of Operations Leaders (OLs) were reinforced. All leadersare expected to comply with the collective agreements and other PHCguidelines and processes, ensure that OT is discussed at staffmeetings, take action where there are situations of excessive OT, anduse available tools and resources. Resources available to managersinclude HR advisors, Scheduling and Labor Relations workshops andthe StatsCard. All OLs will be supported with key and consistentmessaging from Communications, education sessions by LabourRelations and monitoring of actual savings to target by Finance. Theprograms contributing most to the overtime rate will have additionalsupport from Recruitment and Staff scheduling as necessary.

PHC = VCH Fiscal Period 3.1% VCH

Fiscal Period

07/0

8-01

07/0

8-02

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

8-11

07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

% o

verti

me h

ours

0%

1%

2%

3%

4%

5%

6%

7%


Horizontal issues will be addressed: apply Lean thinking to identifying gaps between the HR/Leader/Staffing and for process

improvements within Staff Scheduling Services (ongoing); and strengthen the role and authority of the clinical coordinators (in process).

Efficiency

Efficiency



11.29. Productive nursing hours per patient day (RN, LPN) Definition The average number of staff worked hours that relate directly to patient care or being "on the job" per census day.

Analysis For FY 09/10, the actual productive RN hours per patient day of 2.85was higher than the budget of 2.79. This difference of 0.06 hours ishigher than the 0.01 hour difference between the actual and budgetproductive RN hours for FY 08/09; therefore, there has been noimprovement. The actual productive LPN hours per patient day of 1.18for FY 09/10 was higher than the budget of 1.15. This difference of 0.03hours is an improvement from the 0.25 difference between the actualand budgeted hours from 08/09. Next Steps Continue to monitor the progress of this indicator.

Type

Report Frequency


Summary Symbol

PHC Fiscal Period - - -

Fiscal Period

07/0

8-01

07/0

8-02

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

8-11

07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

Prod

uctiv

e nur

sing

hour

s per

pa

tient

day

0

1

2

3

RN Actual RN Budget RN AvgLPN Actual LPN Budget LPN Avg

Effectiveness

Live Our Mission


2

2.1. % positive responses to survey items related to Spirituality Definition Proportion of responses that were positive for selected items related to Spirituality on the Acute Inpatient, Emergency Department,Long Term Care Resident, and Living Our Mission Every Day Staff Surveys.

Type Report

Frequency Preferred


Analysis In the 2008 Acute Inpatient Sector Patient Satisfaction Survey, 46.2%of those who stated that spiritual needs were an important part of careresponded positively that their spiritual needs were met. This rate islower than the rate of 62.3% in the 2005 survey. A decrease was alsoseen in the 2008 ED Patient Experience Survey where 48.9% of EDpatients responded positively that their spiritual needs were met. Therate is significantly lower than the rate of 76.2% for the 2007 survey.The target of 80% was not met in either survey. Next Steps Conduct focus groups with patients to get a better understanding ofwhat spirituality means to them (Mission Services will conduct these inthe Fall). Intensify the orientation sessions for physicians, staff, andleaders. The new values competency framework entitled “Bringing OurValues to Life” was released at ELF in April. Several educationinitiatives based on this framework will be implemented throughout theyear to assist staff in integrating PHC’s core values into everydaydecision-making and behaviours.

PHC Survey Year 80% -

% p

ositi

ve re

spon

ses

0%

20%

40%

60%

80%

100%

Target 2005 2006

2008

Acuteinpatients

ED patients OP oncologypatients

StaffResidents

2004 20072009

2.2. % positive responses to survey items related to Integrity Definition Proportion of responses that were positive for selected items related to Integrity on the Gallup Employee Engagement Survey.

Type Report

Frequency Preferred


Analysis In the 2009 Employee Engagement Survey, 54% of staff respondedpositively that the values of PHC impact decision-making in their areaof work. This is an improvement from 48% in previous survey in 2007but still does not meet the target of 60%. Next Steps The new values competency framework entitled “Bringing Our Valuesto Life” was released at ELF in April. Several education initiatives basedon this framework will be implemented throughout the year to assiststaff in integrating PHC’s core values into everyday decision-makingand behaviours.


2007 2009

% p

ositi

ve re

spon

ses

0%

20%

40%

60%

80%

100%

PHC Target

Effectiveness

Effectiveness

Live Our Mission


2

2.3. % positive responses to survey items related to Trust Definition Proportion of responses that were positive for selected items related to Trust on the Acute Inpatient, Emergency Department, LongTerm Care Resident, Long Term Care Resident Family, and Living Our Mission Every Day Staff Surveys.

Analysis In 2008, both the Acute Inpatient Sector Patient Satisfaction Survey,and the ED Patient Satisfaction Surveys saw an increase in thepercentage who responded positively that they had confidence andtrust in the nurses and doctors treating them. The rates of 76.4% and77.8% for acute inpatients and ED patients, respectively, were alsohigher than the BC average. However, the target of 85% was not met ineither survey. Next Steps The new values competency framework entitled “Bringing Our Valuesto Life” was released at ELF in April. Several education initiatives basedon this framework will be implemented throughout the year to assiststaff in integrating PHC’s core values into everyday decision-makingand behaviours.

Type

Report Frequency


Summary Symbol


% p

ositi

ve re

spon

ses

0%

20%

40%

60%

80%

100%

Target 2003 2005 20062008

Acuteinpatients


Staff

20072009

2.4. % positive responses to survey items related to Respect Definition Proportion of responses that were positive for selected items related to Respect on the Acute Inpatient, Emergency Department, LongTerm Care Resident, Long Term Care Resident Family, and Living Our Mission Every Day Staff Surveys.

Analysis In 2008, 79.8% in the Acute Inpatient Sector Patient SatisfactionSurvey and 69.4% in the ED Patient Satisfaction Survey respondedpositively that they were treated with respect and dignity. These ratesare similar to those found in the previous surveys. The rate has beenrelatively stable over time; however, the target of 85% was not met ineither survey. Next Steps The new values competency framework entitled “Bringing Our Valuesto Life” was released at ELF in April. Several education initiatives basedon this framework will be implemented throughout the year to assiststaff in integrating PHC’s core values into everyday decision-makingand behaviours.

Type

Report Frequency


Summary Symbol


% p

ositi

ve re

spon

ses

0%

20%

40%

60%

80%

100%

Target 2003 2005 20062008

Acuteinpatients


Staff

20072009

Effectiveness

Effectiveness

Promote Partnerships


3

3.1. Resident family overall quality rate Definition The proportion of total responses that were positive from residents’ families for Long Term Care/Complex Continuing Care FamilyEvaluation Survey questions about the quality of care provided.

Type Report

Frequency Preferred


Analysis The proportion of positive responses for the Long Term Care FamilySurvey item pertaining to overall quality was 82.6% for 2008, whichmeets the target of 82%. This constitutes no change over the rateachieved in the previous survey conducted in 2004. PHC’s level ofperformance is below the average rate of 88.4% for Canadianresidential care facilities in the survey database. *Note: The 2008 survey database is comprised largely of data forOntario facilities. Next Steps The results of the Family/Visitor Satisfaction Survey have been sharedwith the Interdisciplinary (ID) Team, Residential Leadership Team andPHC Senior Leadership Team. The ID team and Leaders havedetermined priorities for improvement. This will be done in alignmentwith the actions following the Employee Engagement survey resultsand the results of the Self-Assessment Questionnaire for ResidentialCare.

PHC Survey Year 82% Database Avg

% p

ositi

ve re

spon

ses

0%

20%

40%

60%

80%

100%

Resid

ent

Need

s

Dign

ity

Tend

erLo

ving C

are

Reco

mmen

dto

Othe

rs

Over

allQu

ality

PHC 1999 PHC 2004 PHC 2008 Canada Avg 2008Target

Effectiveness



3

3.2. ED patient satisfaction Definition Mean of total responses for the ED patient satisfaction survey question: "Overall, how would you rate the care you received in theEmergency Department?" on the scale 1 to 5, where 1=poor, 2=fair, 3=good, 4=very good, 5=excellent.

Analysis The mean of patients’ responses to the question “Overall, how wouldyou rate the care you received in the Emergency Department?” on thescale 1-5 for the entire period shown is 3.96 for SPH and 3.86 for MSJ.The scores are stable for both sites. Next Steps Continue to monitor the progress of this indicator. Set a target. Useresults to increase awareness, identify educational requirements andfocus improvement efforts.

Type

Report Frequency


Summary Symbol

PHC Calendar Month - VHHSC

Calendar Month

Feb

07M

ar 0

7Ap

r 07

May

07

Jun

07Ju

l 07

Aug

07Se

p 07

Oct

07

Nov

07

Dec

07

Jan

08Fe

b 08

Mar

08

Apr 0

8M

ay 0

8Ju

n 08

Jul 0

8Au

g 08

Sep

08O

ct 0

8N

ov 0

8D

ec 0

8Ja

n 09

Feb

09M

ar 0

9Ap

r 09

May

09

Jun

09Ju

l 09

Aug

09Se

p 09

Oct

09

Nov

09

Dec

09

Jan

10Fe

b 10

Mar

10

Aver

age s

atisf

actio

n sc

ore

3.0

3.5

4.0

4.5

5.0

MSJ MSJ AvgSPH SPH Avg VHHSC

3.3. Acute inpatient satisfaction rate Definition The proportion of total responses from patients that were positive for the Acute Inpatient Satisfaction Survey questions about thequality of care provided.

Analysis The percent of positive responses to the Acute Inpatient SatisfactionSurvey items pertaining to overall quality was 93.4%. This is better thanboth the BC average of 92.1% and the 2005 survey of 91.6%. PHC’slevel of performance was either the same as or better than the 2005survey in all but three of the dimensions. Scores were also better thanthe BC average for five of the dimensions. None of the differences werestatistically significant. Next Steps Establish a target. Continue to implement the Care Delivery ModelRedesign (CDMR) project, which was initiated in March, 2008. Onegoal of the project is to improve performance under the EmotionalSupport and Continuity and Transition dimensions. A ClinicalReconfiguration project, initiated in August, 2009 with a completion goalof Fall 2010, is focusing on having the right patient, on the right unit, forthe right care, which will continue to improve the services provided forimproved patient satisfaction. The next survey is tentatively scheduledfor 2011.

Type

Report Frequency


Summary Symbol

PHC Survey Year - BC Avg

% p

ositi

ve re

spon

ses

0%

20%

40%

60%

80%

100%

Resp

ect

Phys

ical

Comf

ort

Conti

nuity

&Tr

ansit

ion

Info &

Educ

ation

Emoti

onal

Supp

ort

PHC 2005 BC Avg 2008

Likely

toRe

comm

end

Acce

ssto

Care

Over

allQu

ality

Fami

lyInv

olvem

ent

Coor

dinati

onof

Care

PHC 2008

Patient-Centredness

Patient-Centredness

Engage and Develop Our People


4

4.1. Overall engagement rate Definition The grand mean of question 12 in the Employee Engagement Survey to the PHC employees.

Type Report

Frequency Preferred


Analysis The grand mean of the Gallup Q12 in the Employee EngagementSurvey is 3.62. This is a meaningful improvement from the grand meanof 3.48 from the 2007 survey; however, it does not meet the target of3.98 (50th percentile). Next Steps Gallup’s research shows that increased employee engagement isachieved through communicating survey results with all team members,actively engaging in action planning and following up on those actions.As of June 10, 2010, 30% of action plans have been completed, and apresentation of Gallup results and sustainment recommendations willbe made to the Senior Leadership Team with the objective of gettingsustainment commitment.

PHC Calendar Month 3.98 -

2007 2009

Over

all en

gage

men

t

0

1

2

3

4

5

PHC AvgPHC Target

4.2. Difficult to fill vacancy rate Definition The count of vacancies for 1) nurses and 2) Allied health at fiscal period end date, that have been vacant for more than 90 days sinceposted as a proportion of the total vacancies and filled positions at fiscal period end date.

Type Report

Frequency Preferred


Analysis The difficult to fill (DTF) vacancy rate for both nurses and Allied Healthsaw shifts in the desired direction starting P12-08/09. While the FY09/10 DTF rate for nurses is above the target of 2% at 2.7%, the FY09/10 DTF rate for Allied Health meets the target at 1.3%. The declinein DTF positions for both nurses and Allied Health vacancies is due toemployees not leaving their positions at the same rate as in previousyears. Traditionally difficult to fill areas such as the ICU, Emergencyand the Heart Centre are also continuing to be filled with internationalRNs from last year’s campaign and with local/national RNs seekingpermanent employment. Next Steps Continue to monitor the progress of this indicator.


Fiscal Period

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

8-11

07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

DTF

rate

(%)

0%

2%

4%

6%

8%

Nurses Allied HealthAvg (Nurses)

Target (Nurses & Allied Health)Avg (Allied Health)

Effectiveness

Effectiveness



4

4.3. External turnover rate (regular employees)

Definition The number of terminations during the fiscal period as a proportion of the number of regular employees at the start of fiscal period andregular hires during the fiscal period (casuals are excluded).

Analysis The average external turnover rate for regular employees is 3.9% forthose who voluntarily leave the organization, 2.1% for those retiring,and 1.9% for those leaving involuntarily in FY09/10. The spike in P10-09/10 for involuntary turnover was caused by the Lower Mainlandconsolidation. Voluntary turnover has decreased in the latter part of theyear starting P6-09/10. This can be attributed to employees not leavingtheir positions (going casual or part-time) at the same rate as inprevious years due to the economic situation. Next Steps Continue to monitor the progress of this indicator.

Type

Report Frequency


Summary Symbol

PHC Fiscal Period - -

Fiscal Period

07/0

8-01

07/0

8-02

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

8-11

07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

Turn

over

rate

(%)

0%

2%

4%

6%

8%

10%

12%

Voluntary InvoluntaryAvg (Voluntary) Avg (Involuntary)Avg (Retirement)

Retirement

Effectiveness



4

4.4. WSBC MSI (musculoskeletal injury) incidence rate for direct care areas Definition The number of Worksafe BC musculoskeletal injury (MSI) incidents per 100 productive hour FTEs for direct care areas.

Type Report

Frequency Preferred


Analysis The Worksafe BC MSI incidence rate for direct care areas hasdecreased in recent periods. The average rate is 2.2 incidents per 100productive hour FTEs for FY 09/10, which does not meet the target rateof 0. The improved rate reflects the continued training of staff andensuring that the needed equipment is available to them. The follow-upand investigation of incidents has been enhanced. There has also beena fair amount of ceiling lift training, as well as more sliding sheettraining over the past year. PHC has been outperforming VCH in themajority of the last 13 periods. Next Steps Continue to monitor the progress of this indicator. PHC is undertakinga Culture of Safety project funded by WSBC which, in part, is directedto reducing the MSI injury rate further through additional equipment andtraining of staff.

PHC = VCH Fiscal Period 0% VCH

Fiscal Period

07/0

8-01

07/0

8-02

07/0

8-03

07/0

8-04

07/0

8-05

07/0

8-06

07/0

8-07

07/0

8-08

07/0

8-09

07/0

8-10

07/0

8-11

07/0

8-12

07/0

8-13

08/0

9-01

08/0

9-02

08/0

9-03

08/0

9-04

08/0

9-05

08/0

9-06

08/0

9-07

08/0

9-08

08/0

9-09

08/0

9-10

08/0

9-11

08/0

9-12

08/0

9-13

09/1

0-01

09/1

0-02

09/1

0-03

09/1

0-04

09/1

0-05

09/1

0-06

09/1

0-07

09/1

0-08

09/1

0-09

09/1

0-10

09/1

0-11

09/1

0-12

09/1

0-13

Incid

ents

per

100 F

TEs

0

2

4

6

8

10

12


4.5. WSBC experience rating adjustment Definition The surcharge/discount applied to the Worksafe BC base rate (amount charged per $100 of assessable earnings) based on PHC’sinjury costs (for both acute care and residential care sites) relative to the provincial acute care classification unit average.

Type Report

Frequency Preferred


Analysis PHC achieved a discount to the Worksafe BC base rate for its AcuteCare (-25%) and Long Term Care (4.5%) classification units for 2010. Next Steps Refer to Next Steps for 4.4. WSBC MSI incidence rate for directcare areas indicator (page 32).

PHC Calendar Year - VGH/UBCH

% su

rcha

rge/d

iscou

nt

-30%

-25%

-20%

-15%

-10%

-5%

0%

2007

PHC Acute VGH/UBCH Acute

2009Calendar Year

PHC Long Term VGH/UBCH Long TermTarget

Safety

Safety

Foster a Culture of Innovation and Improvement


5

5.1. Total annual research funding Definition Total research funding by type (Contracts and Agreements; CFI, KDF and Matching funds; Other Grants; and Peer-Reviewed Fundingas per Michael Smith Foundation for Health Research (MSFHR) definition) by fiscal year.

Analysis The total annual research funding increased by 0.7% to $32.6 millionfor FY 09/10 from $32.4 million for the previous fiscal year. This waslargely due to a $6.9 million increase in funding through Contracts andAgreements. All other funding sources saw decreases from FY 08/09to FY 09/10. Next Steps Continue to monitor the progress of this indicator annually.

Type

Report Frequency


Summary Symbol

PHC Fiscal Year - -

Fiscal Year 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10

Annu

al re

sear

ch fu

ndin

g(in

milli

ons o

f doll

ars)

0

10

20

30

40

50

Other grant funding Contracts & agreements CFI, KDF & matchingPeer-reviewed funding Clinical trials

$12.2 $13.8

$39.9

$22.8$27.6 $27.4

$23.4$29.1

$32.4 $32.6

5.2. Number of invention disclosures Definition The number of new technologies stemming from research performed at Providence.

Analysis There were 5 invention disclosures stemming from research performedat Providence in FY 09/10. This is lower than previous years and belowthe average. Next Steps Continue to monitor this indicator annually and track differences fromyear to year.

Type

Report Frequency


Summary Symbol

PHC Fiscal Year - -

03/04 04/05 05/06 06/07 07/08 08/09 09/10

Inve

ntio

n di

sclo

sure

s

0

5

10

15

20

Fiscal YearPHC AvgPHC

Effectiveness

Effectiveness

PHC Accountability & Performance Improvement Framework


A

EVALUATE

MISSIONVISION

ANDVALUES

STRATEGIC

DIRECTIONS

AND

GOALS

PERFORMANCE TARGETS AND INDICATORS

Providence Health Care;MoH/VCHA Performance Agreement

PERFORMANCE TARGETS AND INDICATORS

Program, Group or Team

ACT

PLAN

DO

STUDY

- what are we trying to accomplish?

- how will we know that a change is an

improvement?- what changes can we make that will result in

an improvement?

ACT

PLAN

PERFORMANCEEXCELLENCE PLAN

PHC

PROGRAMLive ourMission

Leadthrough

exceptionalcare, service,teaching and

research

Foster aculture ofinnovationandimprovement

Engage anddevelop ourpeople

Promotepartnerships

Advanceour

leadershipin health

care

Dimensions of Quality Matrix


B

Indicator Name Effec

tiven

ess

Safet

y

Timeli

ness

Patie

nt-Ce

ntred

ness

Effic

iency

Lead Through

Exceptional Care,

Service, Teaching

and Research

1.1. COPD readmission rate 1.2. In-hospital mortality rate for community-acquired pneumonia 1.3. % of ST-elevation myocardial infarction patients with door to balloon time less than 90 minutes 1.4. Aspirin administration rate for AMI and suspected AMI 1.5. Prevalence of residents with little or no activities 1.6. Incidence of residents who walk as well or better than previous assessment 1.7. Median CD4 count for HIV/AIDS 1.8. Unplanned readmission rate for mental health and addictions 1.9. Arteriovenous fistula rate for those receiving incident hemodialysis 1.10. Rate of receipt of adequate hemodialysis 1.11. % of patients with at least one adverse event 1.12. In-hospital infection/colonization rate 1.13. Hand hygiene compliance rate 1.14. HSMR (Hospital Standardized Mortality Ratio) 1.15. In-hospital deaths per 100 patients in CMGs with less than 1% mortality 1.16. In-hospital fracture rate per 1,000 patients aged 65 years and older 1.17. Influenza immunization rate for residents 1.18. Influenza immunization rate for staff 1.19. % oncology surgery patients receiving surgery within targeted wait times 1.20. % ALC census days 1.21. Proportion of ED patients seen by provider within targets 1.22. % of admitted patients leaving ED within 10 hours of triage 1.23. % acute LOS (length of stay) compared to ELOS (expected length of stay) 1.24. Cost per weighted case 1.25. Cumulative net surplus (deficit) 1.26. Administrative and support costs as % of total expenses 1.27. % sick hours 1.28. % overtime hours 1.29. Productive nursing hours per patient day (RN, LPN)

Live Our Mission

2.1. % positive responses to survey items related to Spirituality 2.2. % positive responses to survey items related to Integrity 2.3. % positive responses to survey items related to Trust 2.4. % positive responses to survey items related to Respect


3.1. Resident family overall quality rate 3.2. ED patient satisfaction 3.3. Acute inpatient satisfaction rate

Engage and Develop Our

People

4.1. Overall engagement rate 4.2. Difficult to fill vacancy rate (% positions vacant for >90 days that are considered difficult to fill for

1/Nurses 2/Allied health)

4.3. External turnover rate (regular employees) 4.4. WSBC MSI (musculoskeletal injury) incidence rate for direct care areas 4.5. WSBC experience rating adjustment

Foster a Culture of Innovation

and Improvement

5.1. Total annual research funding

5.2. Number of invention disclosures

TECHNICAL NOTES


C

1.1. COPD readmission rate Rationale: This indicator measures PHC’s quality of care for COPD patients. This reflects the rate of patients who are

readmitted for COPD related diagnosis after discharge. This is one of the required indicators for the COPD LMIIF project, “A systems approach to improving COPD management across VCH, PHC and FHA.”

Numerator: The number of cases admitted with a most responsible diagnosis of COPD that were unplanned readmissions to the same facility in ≤28 days for a related diagnosis Inclusion criteria:

• CMG group = 139 AND • Most responsible (Type M) diagnosis of pneumonia (one of following ICD‐10‐CA codes):

o J44.0 COPD with acute lower resp infection o J44.1 COPD with acute exacerbation unspecified o J44.8 Other specified COPD o J44.9 COPD unspecified

AND • Readmission Group = 'Unplanned within 28 Days ‐ Previous Acute Admission'

Denominator: Total number of cases admitted with most responsible diagnosis of COPD Inclusion criteria:

• CMG group = 139 AND • Most responsible (Type M) diagnosis of pneumonia (one of following ICD‐10‐CA codes):

o J44.0 COPD with acute lower respiratory infection o J44.1 COPD with acute exacerbation unspecified o J44.8 Other specified COPD o J44.9 COPD unspecified

Calculation: numerator/denominator*100

Data source: Health Records

Data limitation: Cases that are readmitted to a different facility are not counted since the readmission code only includes readmissions to the same facility

Target source: LMIIF (based on 07/08 data from VCH and PHC)

Comparator source: VCH DAD cube

References: ‐

Notes: ‐

TECHNICAL NOTES


C

1.2. In‐hospital mortality rate for community‐acquired pneumonia Rationale: Community‐acquired pneumonia has an annual incidence of 12 per 1000 adults and is the sixth most

common cause of death. Studies have demonstrated that certain processes of care (e.g. early antibiotic administration upon hospital arrival, blood culture collection within 24 hours of hospital arrival, oxygenation assessment) can lead to decreased mortality associated with pneumonia.

Numerator: Number of cases with most responsible diagnosis of community‐acquired pneumonia who die in hospital

Denominator: Total number of cases with most responsible diagnosis of community‐acquired pneumoniaInclusion criteria: • Most responsible (Type M) diagnosis of pneumonia (one of following ICD‐10‐CA codes):

J120 Adenoviral pneumonia J121 Respiratory syncytial virus pneumonia J128 Other viral pneumonia J129 Viral pneumonia unspecified J13 Pneumonia dt Streptococcus pneumoniae J14 Pneumonia due to Haemophilus influenzae J150 Pneumonia due to Klebsiella pneumoniae J151 Pneumonia due to Pseudomonas J152 Pneumonia due to Staphylococcus J153 Pneumonia due to Streptococcus, group B J154 Pneumonia due to other streptococci J155 Pneumonia due to Escherichia coli J156 Pneumonia dt other aerobic gram neg bact J157 Pneumonia dt Mycoplasma pneumoniae J158 Other bacterial pneumonia J159 Bacterial pneumonia unspecified J160 Chlamydial pneumonia J170 Pneumonia in bacterial diseases classified elsewhere J171 Pneumonia in viral diseases classified elsewhere J172 Pneumonia in mycoses J173 Pneumonia in parasitic diseases J168 Pneumonia dt oth spec infect organisms J180 Bronchopneumonia unspecified J181 Lobar pneumonia unspecified J188 Other pneumonia organism unspecified J189 Pneumonia unspecified Exclusion criteria: • Patients with one of the above ICD‐10‐CA diagnosis codes listed as both MRDx AND Type 2 (post‐

admit co‐morbidity) on discharge abstract as this represents a hospital‐acquired pneumonia • Cases transferred to another acute care hospital • Cases ≤ 18 years



Data limitation: At the start of FY 04/05, Health Records implemented coding changes that affect how the most responsible diagnosis is determined for patients with both pneumonia and COPD (chronic obstructive pulmonary disease) in adherence with CIHI coding guidelines.

Target source: ‐

TECHNICAL NOTES


CComparator source: American Thoracic Society (see reference below)

References: 1. Bartlett JG, Mundy LM. Community‐acquired pneumonia. New England Journal of Medicine 1995; 333(24):1618‐24.

2. McGarvey RN, Harper JJ. Pneumonia Mortality Reduction and Quality Improvement in a Community Hospital. Quality Review Bulletin (QRB) 1993; 19: 124‐129.

3. Meehan TP et al. Process of care performance, patient characteristics, and outcomes in elderly patients hospitalized with community‐acquired or nursing home‐acquired pneumonia. Chest 2000; 117(5): 1378‐85.

4. Neiderman MS et al. (American Thoracic Society) Guidelines for the Initial Management of Adults with Community‐Acquired Pneumonia: Diagnosis, Assessment of Severity, and Initial Antimicrobial Therapy. American Review of Respiratory Diseases 1993; 148: 1418‐26.

Notes: ‐

TECHNICAL NOTES


C

1.3. % of ST‐elevation myocardial infarction patients with door to balloon time less than 90 minutes

Rationale: Door to balloon time refers to the time from the patient's arrival at the hospital to intracoronary balloon inflation during primary percutaneous coronary intervention. Delays in treating ST‐elevation myocardial infarction (STEMI) increase the likelihood and amount of cardiac muscle damage. As such, it is important to ensure the door‐to‐balloon interval is no more than the target of 90 minutes.

Numerator: Number of patients with most responsible diagnosis of STEMI, with a door to balloon time (time from hospital arrival to PCI‐percutaneous coronary intervention) less than the target of 90 minutes

Denominator: Number of patients with most responsible diagnosis of STEMI


Data source: Heart Centre

Data limitation: ‐

Target source: American College of Cardiology, American Heart Association, Door‐to‐Balloon (D2B) Alliance, Canadian Cardiovascular Outcomes Research Team, Safer Healthcare Now!

Comparator source: ‐

References: 1. ACC/AHA Guidelines for the Management of Patients With ST‐Elevation Myocardial Infarction, J Am Coll Cardiol, 2004; 44: 671‐719

2. Nallamothu BK, Krumholz HM, Peterson ED, Pan W, Bradley E, Stern AF, Masoudi FA, Janicke DM, Hernandez AF, Cannon CP, Fonarow GC. Door‐to‐Balloon Times in Hospitals within the Get‐With‐The‐Guidelines Registry after Initiation of the Door‐to‐Balloon (D2B) Alliance. Am J Cardiol, 2009; 103: 1051–1055.

3. Kushner, Frederick et al. "2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST‐Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update)." Circulation. 2009; 120: 2271‐2306.

Notes: STEMI patients are a subset of all AMI patients

TECHNICAL NOTES


C

1.4. Aspirin administration rate for AMI and suspected AMI Rationale: The benefits of administering aspirin for the treatment of suspected myocardial infarction is well

established in the literature. The immediate administration of aspirin (and continued administration for 5 weeks) has been shown to reduce vascular deaths by 23%. When all high‐risk patients are considered together, there is about a 30% reduction in nonfatal MI, a 30% reduction in nonfatal stroke, and a 17% reduction in vascular death. For patients with prior infarction or stroke, aspirin is estimated to prevent between 35 and 40 events per 1000 patients treated.

Numerator: Number of inpatient discharges with diagnosis of suspected or confirmed myocardial infarction with an order for a regular dose of aspirin during hospitalization

Denominator: Number of inpatient discharges with diagnosis of suspected or confirmed myocardial infarctionInclusion criteria: Cases with one of the following ICD‐10‐CA codes designated as the most responsible, Type 1, or Type 2 diagnosis: • Chest pain/angina: I200‐I209, I2382, R071‐R074 • Myocardial infarction: I210‐I229

Exclusion criteria: • Holy Family Hospital • Cases with LOS = 1 day • Cases < 12 years • MCC 13 – obstetric discharges • MCC 14 – newborns and other neonates with conditions originating in the perinatal period


Data source: Health Records & Pharmacy System

Data limitation: The calculated aspirin administration rate may be lower than the actual rate due to the following:• STAT orders of aspirin are not consistently entered in the Pharmacy System and are thus excluded

from the calculation of the indicator. • The denominator may include ineligible patients who have contraindications to aspirin due to: lack of

specificity of coding contraindications to aspirin, incomplete documentation of aspirin contraindications in patient charts, and the incomplete coding of those aspirin contraindications that are documented

Target source: • Safer Healthcare Now • CCORT/CCS AMI quality indicators, Can J Cardiol 19(1): 38‐45; January 2003


References: 1. ISIS‐2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both or neither among 17,187 cases of suspected acute myocardial infarction. Lancet 1988; ii: 349‐60.

2. Bing, M et al. Aspirin Administration for Cardiac‐related Acute Chest Pain/Angina: Increased Use in Medicare Patients. Southern Medical Journal 1999; 92(1): 23‐27.

Notes: ‐

TECHNICAL NOTES


C

1.5. Prevalence of residents with little or no activities Rationale: This indicator measures what residents are doing when they are not receiving care. It is an indication of

whether patients feel comfortable, able, mobile and supported enough to do what they want to do. This indicator follows the EDEN philosophy, which provides guidance on how we can help elders continue to live meaningful lives when they become too frail to live independently.

Numerator: Number of Resident patients from the Denominator, with little or no activity on most recent assessment(Time involved in activities is little or none: Section N2=2,3)

Denominator: Number of residents with completed/closed MDS assessmentsExclusions:

‐ The resident is comatose (Section B1=1)


Data source: Resident Assessment Instrument Residential Care (RAI RC) Minimum Data Set (MDS) 2.0 (copyright InterRAI) Canadian version (copyright CIHI, 2002)

Data limitation: Requires a good rate of MDS assessment completion to be representative.

Target source: Consultation with internal experts.


References: “Validation of Long‐Term and Post Acute Care Quality Indicators” CMS contract # 500‐95‐0062/T.O. #4 Final report June 2003

Notes: ‐

TECHNICAL NOTES


C


Rationale: This is a “balancing measure,” an indirect measure, used to track the effect of daily care. This indicator focuses on our ability to maintain function while ensuring least restraint, preventing injury due to falls, and managing unsettled behavior. This measure is evidence based. It has been validated as being indicative of care being preventive and responsive.

Numerator: Number of Resident patients from the Denominator, whose Walking is the same or better in the most recent assessment, compared to the previous assessment

Denominator: Number of residents that had an assessment done in the reported quarter and the previous quarterInclusions:

‐ Capacity to stand on the prior or the most recent assessment (G3a=0,1,2) OR ‐ Capacity to walk on the prior assessment (G1d(A)=0,1,2,3)

Exclusions: ‐ The resident is comatose (B1=1) ‐ The resident has end‐stage disease (J5c checked) ‐ The resident is receiving hospice care (P1ao checked)


Data source: Resident Assessment Instrument Residential Care (RAI RC) Minimum Data Set (MDS) 2.0 (copyright InterRAI) Canadian version (copyright CIHI, 2002)

Data limitation: Requires a good rate of MDS assessment completion to be representative.



References: “Validation of Long‐Term and Post Acute Care Quality Indicators” CMS contract # 500‐95‐0062/T.O. #4 Final report June 2003

Notes: ‐

TECHNICAL NOTES


C

1.7. Median CD4 count Rationale: CD4 counts are tests conducted on blood samples used to assess the strength of patients’ immune

systems and can also be used to determine the efficacy of treatment. Median CD4 count at a population level is a reflection on the immune status of the population. Lower CD4 counts have been used as proxy for increased morbidity and mortality and higher acute health services utilization. The goal is to keep CD4 counts >350.

Numerator: Median CD4 count of patients defined below:Patient selection: • Patients in SPH IDC clinic that are active (meaning they have had at least 2 visits within the past year) –

not inpatients. • Exclude deaths Process specifications: • Take the latest CD4 test within the last 4 months. • Take the minimum CD4 test result (might have multiple results during one test/visit).

Denominator: ‐

Calculation: ‐

Data source: IDC database

Data limitation: Patients might be tested in other labs, and if this is the case, the data of that testing is not available. However, SPH does about 85% of the testing in BC and for IDC patients, the percentage tested outside of SPH is very small.

Target source: Therapeutic Guidelines ‐ BC Centre for Excellence in HIV/AIDS

Comparator source:

References: www.cfenet.ubc.ca

Notes: ‐

TECHNICAL NOTES


C

1.8. Unplanned readmission rate for mental health and addictions Rationale: Readmission rate may be a measure of the effectiveness of in‐hospital treatment and discharge

planning.

Numerator: Number of cases that were readmissions to the same facility in ≤ 28 days for a related diagnosisInclusion criteria:

• Cases with readmission code = 2 or 3

Denominator: Total number of mental health and addictions casesInclusion criteria:

• Cases aged between 15 and 64 years, inclusive • Cases with one of the following ICD‐10‐CA codes as the most responsible diagnosis (MRDx): F0*,

F1*, F2*, F3*, F4*, F50*, F51*, F52*, F530*, F531*, F6*, F840*, F841*, F843*, F844*, F845*, F848*, F849*, F9*, Z281*, Z55*, Z56*, Z57*, Z600*, Z601*, Z603*, Z604*, Z605*, Z608*, Z609*, Z61*, Z62*, Z63*, Z640*, Z641*, Z644*, Z65*, Z720*, Z721*, Z722*, Z723*, Z724*, Z725*, Z726*, Z729*, Z730*, Z731*, Z732*, Z733*, Z734*, Z735*, Z738*, Z739*, R410*, G312*, G442*



Data limitation: • At the start of FY 04/05, the Ministry of Health Services changed its definition of mental health cases to those with a most responsible diagnosis in specific mental health and addictions codes. Additionally, it restricted its definition to those patients between the ages of 15 and 65. The definition of addictions is problematic as it relies on an addictions diagnosis being coded as the most responsible diagnosis, therefore use of this definition may lead to the underrepresentation of the true addictions population. All past data has been recompiled to reflect this new definition.

• Due to changes made by CIHI in the coding of readmissions for fiscal year 03/04, data prior to this time are unavailable.

Target source: BC Ministry of Health Services – Performance Agreement

Comparator source: VCH

References: Ministry of Health Services, Service Plan 2003/04 – 2005/06.

Notes: ‐

TECHNICAL NOTES


C

1.9. Arteriovenous fistula rate for those receiving incident hemodialysis Rationale: An arteriovenous fistula (AVF) is a connection between an artery and a vein that can be surgically

created in order to enlarge the vein to allow for hemodialysis. AVFs are superior to grafts and catheters due to greater patency, decreased morbidity and mortality and decreased costs.

Numerator: Number of chronic hemodialysis patients who start hemodialysis, and the first access used is an AV Fistula, within a specified timeframe

Denominator: Total number of patients started on hemodialysis during the same specified timeframe


Data source: Patient Record and Outcome Management Information System (PROMIS)

Data limitation: Meaningful analysis is made difficult due to the low case counts per annual quarter.

Target source: Canadian Guidelines/Consultation with internal experts. According to Canadian guidelines, an arteriovenous fistula should be attempted in 50% of new patients.


References: Provincial Vascular Access Team (PVAST) Provincial Quality Indicators.

Notes: ‐

TECHNICAL NOTES


C

1.10. Rate of receipt of adequate hemodialysis Rationale: Adequacy of dialysis is associated with morbidity and mortality of dialysis patients.

Numerator: Number of hemodialysis patients receiving adequate dialysisInclusion criteria: Hemodialysis patients with PRU ≥ 0.65 on last measurement within 2 months of the fiscal period end date

Denominator: Number of hemodialysis patients with a PRU measurement within 2 months of the fiscal period end date


Data source: Patient Record and Outcome Management Information System (PROMIS)


Target source: Consultation with internal experts


References: 1. BCPRA/PHSA. Proposed Financial and Clinical Indicators by which to evaluate care and delivery. August 2002.

2. Basile C, Casino F, Lopez T. Percent reduction in blood urea concentration during dialysis estimates Kt/V in a simple and accurate way. Am J Kidney Dis 1990; 15(1):40‐5.

Notes: Percent reduction of urea (PRU) (definition): An alternative measure of dialysis adequacy. It is a function of dialyzer urea clearance, length of dialysis, and urea distribution volume of the patient.

TECHNICAL NOTES


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1.11. % of patients with at least one adverse event (Global Trigger Tool) Rationale: This indicator measures the prevalence of adverse events within the acute inpatient population using the

IHI Global Trigger Tool (GTT). Tracking adverse events over time is a useful way to tell if changes being made are improving the safety of the care processes.

Numerator: Number of cases with at least one adverse event

Denominator: Total number of audited cases


Data source: Global trigger tool database (data entered by the clinical care analysts doing the audit)

Data limitation: The number of events is diminished as some patients have more than one event during their hospital stay.

Target source: Consultation with internal experts

Comparator source: *Note: It is important that we do NOT compare numbers elicited using the Global Trigger Tool – it is not a tool that is meant to benchmark between organizations.

References: www.ihi.org

Notes: • The GTT identifies adverse events, determines their frequency and assigns a level of harm rating. This information can then be used to focus resources to improve the safety of care delivery systems.

• Every month, 20 cases from SPH and 20 cases from MSJ, are randomly chosen (by the Health Records department). Clinical care analysts perform an audit on these cases; they have exact 20 minutes for each case.

• Adverse Event (definition): Unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death.

TECHNICAL NOTES


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1.12. In‐hospital infection/colonization rate Rationale: Rates of hospital‐associated infections reflect a multitude of factors, including patient population hand

hygiene compliance, laboratory practices, surveillance system refinements, and infection control awareness and practices among health care workers. This indicator monitors trend in PHC‐associated transmission, and provides a means of determining when interventions might be warranted.

Numerator: Laboratory confirmed cases of infection from specimens indicative of colonization or infection in cases admitted for ≥ 72 hours in a PHC facility or admitted to a PHC facility within the preceding 4 weeks

Denominator: Number of acute, inpatient census days


Data source: Infection Prevention and Control (IPAC)

Data limitation: • VRE data for FY2005/06 is only available for fiscal periods 6‐13 (August 12, 2005 – March 31, 2006). • Clostridium difficile infection (CDI) data for FY2006/07 is only available for fiscal periods 11‐13

(December 29, 2006 – March 31 2007). Enhanced surveillance for CDI began at PHC on January 1, 2007.

Target source: ‐


References: 1. Poutanen SM, Simor AE. Clostridium difficile‐associated diarrhea in adults. CMAJ. Jul 6 2004;171(1):51‐58.

2. McFarland LV. Epidemiology of infectious and iatrogenic nosocomial diarrhea in a cohort of general medicine patients. Am J Infect Control. Oct 1995;23(5):295‐305.

3. Canadian Nosocomial Infection Surveillance Program. Clostridium difficile‐Associated Disease (CDAD) Surveillance, 2004‐2005 Preliminary Results.: Public Health Agency of Canada; March 31 2008.

Notes: ‐

TECHNICAL NOTES


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1.13. Hand hygiene compliance rate Rationale: Hand hygiene (hand‐washing with soap and water or using a hand gel/foam) is likely the most important

measure for preventing the spread of microorganisms in health care settings. However, overall compliance with hand hygiene is known to be low. Monitoring hand hygiene is an essential component of programs aimed at improving compliance. Direct observation is known as a reliable method to measure trends in hand hygiene practices.

Numerator: Number of compliant hand hygiene events *Note: Infection control practitioners measure compliance by directly observing staff on each unit. A compliant hand hygiene event was when the health care workers (HCW) washed their hands or used hand gel/foam before touching the patient, or after touching the patient or the patient’s environment. Putting on new gloves prior to touching a patient was not considered a compliant hand hygiene event in the absence of hand washing or gel use.

Denominator: Number of hand hygiene opportunities. This includes hand hygiene opportunities before or after any staff to patient contact


Data source: Infection Prevention and Control (IPAC)




References: ‐

Notes: Infection Prevention and Control commenced quarterly hand hygiene audits on acute care units at SPH and MSJ and rehab units at HFH in December 2008 and in the EDs at SPH and MSJ in April 2009.

TECHNICAL NOTES


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1.14. HSMR (hospital standardized mortality ratio) Rationale: This indicator tracks how PHC’s mortality rate compares to the national rate (based on 2004/2005 data)

for conditions accounting for 80% of inpatient mortality.

Numerator: The actual number of deaths for SPH and MSJInclusion criteria:

• Discharged in one of the diagnosis groups (based on most responsible diagnosis – exceptions are noted below) that account for 80% of acute care in‐hospital mortality (based on FY 04/05 data in the Discharge Abstract Database):

A04 Other bacterial intestinal infections I61* Intracerebral haemorrhage

A41* Other septicaemia I62* Other nontraumatic intracranial haemorrhage

C16 Malignant neoplasm of stomach I63* Cerebral infarction

C18 Malignant neoplasm of colon I64* Stroke, not specified as haemorrhage or infarction

C22 Malignant neoplasm of liver and intrahepatic bile ducts

I71 Aortic aneurism and dissection

C25 Malignant neoplasm of pancreas J18* Pneumonia, organism unspecified

C34 Malignant neoplasm of bronchus and lung J44* Other chronic obstructive pulmonary disease

C50 Malignant neoplasm of breast J69 Pneumonitis due to solids and liquids

C61 Malignant neoplasm of prostate J80 Adult respiratory distress syndrome

C67 Malignant neoplasm of bladder J84 Other interstitial pulmonary diseases

C71 Malignant neoplasm of brain J90 Pleural effusion, not elsewhere classified

C78 Secondary malignant neoplasm of respiratory and digestive systems

J95 Postprocedural respiratory disorders, not elsewhere classified

C79 Secondary malignant neoplasm of other sites J96 Respiratory failure, not elsewhere classified

C80 Malignant neoplasm without specification of site K55 Vascular disorders of intestine

C83 Diffuse non‐Hodgkin’s lymphoma K56 Paralytic ileus and intestinal obstruction without hernia

C85 Other and unspecified types of non‐Hodgkin’s lymphoma

K57 Diverticular disease of intestine

C90 Multiple myeloma and malignant plasma cell neoplasms

K63 Other diseases of intestine

C91 Lymphoid leukaemia K65 Peritonitis

C92 Myeloid leukaemia K70 Alcoholic liver disease

E11 DM type 2 K72 Hepatic failure

E86 Volume depletion K74 Fibrosis and cirrhosis of liver

F03 Unspecified dementia K85 Acute pancreatitis

G30 Alzheimer’s disease K92 Other diseases of digestive system

G93 Other disorders of brain N17 Acute renal failure

I20 Angina pectoris N18 Chronic renal failure

I21* AMI N19 Unspecified renal failure

I25* Chronic ischaemic heart disease N39 Other disorders of urinary system

I26 Pulmonary embolism R57 Shock, not elsewhere classified

I46 Cardiac arrest S06* Intracranial injury

I48 Atrial fibrillation and flutter S72 Fracture of femur

I50 Heart failure T81 Complications of procedures, not elsewhere classified

I60* Subarachnoid haemorrhage Z54 Convalescence

• Exceptions: o Cases with I125.0, I25.1, I25.8, I25.9 as MRDx AND I21 or I22 as type 1, W, X, Y diagnosis

AND 1IJ76, 1IJ50, 1IJ57GQ, 1IJ54GQAZ in any procedure code field (excluding abandoned procedures) group to I21 diagnosis group

o Cases with Z50 as MRDx AND I60, I61, I62, I63, I64 as type 1, W, X, Y diagnosis group to the diagnosis group corresponding to the type 1, W, X, Y diagnosis (e.g. a case with Z50

TECHNICAL NOTES


C as the MRDx and I62 as a type 1 diagnosis group to the I62 diagnosis group

o Cases with J10.0, J11.0, J12‐J16, J18 as MRDx AND J44 in any diagnosis field group to the J44 diagnosis group

o Cases with J12‐J17 as MRDx group to the J18 diagnosis group o Cases with septicaemia (A42.7, A22.7, A26.7, A28.2, A54.8, A32.7, A39.2, A39.3, A40,

A39.4, A21.7, B00.7, B37.7) as MRDx group to the A41 diagnosis group o Cases with concussion (S06.0) as MRDx are excluded from the S06 diagnosis group

• Age at admission between 0 and 120 years • Gender recorded as male or female • Length of stay of up to 365 days • Admission category = elective or emergent/urgent • Canadian resident

Exclusion criteria: • Cadavers, stillborns, sign‐outs (discharge disposition = ‘08’, ‘09’, ‘06’) • Palliative care patients: Excludes those with Most responsible diagnosis code of ICD‐10‐CA Z51.5

(does NOT exclude Z51.5 as any Dx code other than MRDx, does NOT exclude Main patient service 58 or Patient service transfer 58)

• Neonates, age of admission less than or equal to 28 days Records with brain death as most responsible diagnosis code (ICD‐10‐CA G93.81)

Denominator: The expected number of deaths for SPH and MSJA logistic regression model was fitted with the following independent variables using FY 04/05 CIHI DAD (Discharge Abstract Database) data: Age Gender Length of stay group (1 day, 2 days, 3‐9 days, 10‐15 days, 16‐21 days and 22‐365 days) Diagnosis group (one of the 64 listed in the Numerator) Co‐morbidity group (0, 1 or 2, or above 2), based on the Charlson Index Score (see below) Transfers in from an acute care institution (1 = transferred in; 0 = not transferred in)

dTransferre2GroupCharlson1GroupCharlson54ZgroupDiagnosis

...04AgroupDiagnosisAdmissionUrgent6GroupLOS...1GroupLOSGenderMaleAgep1

pln

68676665

9873210

β+β+β+β

β+β+ββ+β+β+β=

−

where p = probability of death and the values for the intercept 0(β ) and coefficients 68...1(β ) are as follows:

Intercept ‐10.02076635 C71 3.204330888 I50 2.318700053 K65 3.125238119

Age 0.049421589 C78 3.289504981 I60 4.13533699 K70 3.784710659

Male Gender 0.089877221 C79 2.845152688 I61 4.132785911 K72 3.578499341

LOS Group 1 1.30996391 C80 4.162747792 I62 3.268740335 K74 3.04992362

LOS Group 2 0.586673113 C83 3.526005334 I63 2.744590863 K85 1.625831174

LOS Group 4 0.008285513 C85 3.489361813 I64 2.904384482 K92 1.653789831

LOS Group 5 0.15369005 C90 3.328205462 I71 3.361110553 N17 2.888459684

LOS Group 6 0.41813118 C91 3.694611352 J18 2.592184929 N19 3.020324166

Urgent Admission 0.952870069

C92 4.128885546 J44 2.190318194 N39 3.022992139

A04 2.138329449 E11 1.709547075 J69 3.945210039 R57 1.054527292

A41 3.844419508 E86 1.645962024 J80 4.711810769 S06 4.921870748

C16 2.95151913 F03 1.089797666 J84 3.440907965 S72 3.525099349

C18 2.287913068 G30 1.387110241 J90 1.894110374 T81 1.708845213

C22 3.622149881 G93 1.786564441 J95 2.72834879 Z54 1.283373998

C25 3.250755755 I20 5.047277083 J96 4.105485506 Charlson Group1 0.667345993

C34 3.41883293 I25 2.492998275 K55 3.518642867 Charlson Group2 1.238605344

TECHNICAL NOTES


CC50 1.178052132 I26 1.043129892 K56 1.61597973 Transferred 0.303674928

C61 1.719912821 I46 2.567307695 K57 1.111802134

C67 1.275092169 I48 5.655223621 K63 3.053188043

*Note: The above intercept and coefficients are based on FY 04/05 data and applied to all reported years. P (probability of death) is calculated for each case based on the above equation and the total expected number of deaths is the arithmetic sum of the all the case probabilities.

Calculation of the Charlson Comorbidity Group:• The Charlson Index Score is calculated by summing the weights associated with each comorbidity

type that is present as a Type 1, W, X, or Y diagnosis based on the following ICD‐10‐CA codes:

Comorbidity type

ICD‐10‐CA codes Weight

Myocardial infarction

'I21','I22','I252' 1

Congestive heart failure

'I43','I50','I099','I110','I130','I132','I255','I420','I425','I426','I427','I428','I429','P290' 1

Peripheral vascular disease

'I70','I71', 'I731','I738','I739','I771','I790','I792','K551','K558','K559','Z958','Z959' 1

Cerebrovascular disease

‘G45','G46','I60','I61','I62','I63','I64','I65','I66','I67','I68','I69','H340' 1

Dementia 'F00','F01','F02','F03','G30','F051','G311' 1

Chronic pulmonary disease

J40','J41','J42','J43','J44','J45','J46','J47','J60','J61','J62','J63','J64','J65','J66','J67','I278', 'I279', 'J684','J701','J703'

1

Connective tissue disease – rheumatic disease

'M05','M32','M33','M34','M06','M315','M351','M353','M360' 1

Peptic ulcer disease 'K25','K26','K27','K28' 1

Mild liver disease 'B18','K73','K74','K700','K701','K702','K703','K709','K717','K713','K714','K715','K760', 'K762', 'K763','K764','K768','K769','Z944'

1

Diabetes without complications

'E100','E101','E106','E108','E109','E110','E111','E116','E118','E119','E120','E121','E126', 'E128','E129','E130','E131','E136','E138','E139','E140','E141','E146','E148','E149'

1

Diabetes with complications

'E102','E103','E104','E105','E107','E112','E113','E114','E115','E117','E122','E123','E124', 'E125','E127','E132','E133','E134','E135','E137','E142','E143','E144','E145','E147'

2

Paraplegia and hemiplegia

'G81','G82','G041','G114','G801','G802','G830','G831','G832','G833','G834','G839’ 2

Renal disease 'N18','N19','N052','N053','N054','N055','N056','N057','N250','I120','I131','N032','N033', 'N034', 'N035','N036','N037','Z490','Z491','Z492','Z940', 'Z992'

2

Cancer 'C00','C01','C02','C03','C04','C05','C06','C07','C08','C09','C10','C11','C12','C13','C14', 'C15','C16','C17','C18','C19','C20','C21','C22','C23','C24','C25','C26','C30','C31','C32', 'C33','C34','C37','C38','C39','C40','C41','C43','C45','C46','C47','C48','C49','C50','C51', 'C52','C53','C54','C55','C56','C57','C58','C60','C61','C62','C63','C64','C65','C66','C67', 'C68','C69','C70','C71','C72','C73','C74','C75','C76','C81','C82','C83','C84','C85','C88', 'C90', 'C91','C92','C93','C94','C95','C96','C97'

2

Moderate or severe liver disease

'K704','K711','K721','K729','K765','K766','K767','I850','I859','I864','I982' 3

Metastatic carcinoma

'C77','C78','C79','C80' 6

HIV/AIDS 'B20','B21','B22','B24' 6

• The Index Score is then categorized into one of the following Comorbidity Groups: 0, 1 or 2 or more than 2.

• Multiple diagnoses that are present for the same comorbidity type are only counted once. For example, if a patient had two diabetes with complications diagnoses, the weight would be 2 and not 4.

• If one of the above type 1, W, X, or Y codes is used to group a case to a diagnosis group, then the diagnosis would NOT be included in the calculation of that case’s Charlson Index Score (e.g. a case

TECHNICAL NOTES


C with MRDx of Z50 and I61 as a type 1 diagnosis would group to the I61 diagnosis group. The type 1 I61 diagnosis would not be used in the Charlson Index calculation as it was already used to assign the diagnosis group)

Calculation: numerator/denominator*100• Confidence Interval:

o Lower control limit: O/E * (1 – 1/(9 * O) – 1.96/(3 * sqrt(O)))3) * 100 o Upper control limit: (O + 1)/E * (1 – (1/(9 * (O + 1))) + 1.96/(3 * sqrt(O + 1)))3 * 100

O = actual number of deaths E = expected number of deaths


Data limitation: CIHI revised its methodology for HSMR calculation in February 2009 and the HSMR was recalculated back to the FY 04/05.



References: www.cihi.ca/hsmr

Notes: Charlson Index score (definition): The Charlson Index contains categories of comorbidity each of which is associated with a weight, which is based on the adjusted risk of one‐year mortality. The overall score is the cumulative increased likelihood of one‐year mortality. A ratio of 100 indicates that the organization’s mortality rate is no different than the average rate.

TECHNICAL NOTES


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1.15. In‐hospital deaths per 100 patients in CMGs with less than 1% mortality

Rationale: This indicator measures the number of deaths among patients with a low likelihood of dying during their hospitalization. The assumption is that when patients being cared for a condition that is associated with a low risk of mortality die in hospital, the death may be the result of substandard care.

Numerator: Number of in‐hospital deaths in CMGs with less than 1% mortality

Denominator: Total number of inpatient cases in CMGs with less than 1% mortality based on FY 02/03 data from hospitals participating in the Hay Group Benchmarking Reports Inclusion criteria:

• Cases coded under one of the following CMGs (list based on 08/09 data): Medical: 029 Transient Ischemic Attack 034 Other Disorder of Nerve 040 Seizure Disorder 041 Migraine/Other Headache 063 Inflammation of Orbit 064 Major Ophthalmology Disorder 065 Other Ophthalmology Disorder 095 Sleep Apnea 097 Influenza/Acute Upper Respiratory Infection 098 Dysequilibrium/Hearing Loss 099 Epistaxis 101 Disease of Oral Cavity/Salivary Gland/Jaw 103 Tonsillitis/Pharyngitis 105 Miscellaneous Ear/Nose/Throat Disorder 141 Upper/Lower Respiratory Infection 147 Asthma 201 Arrhythmia with Cardiac Catheter 203 Unstable Angina/Atherosclerotic Heart Disease with Cardiac Cath 205 Syncope 206 Benign Hypertension 207 Angina (except Unstable)/Chest Pain with Cardiac Catheter 208 Angina (except Unstable)/Chest Pain without Cardiac Catheter 249 Enteritis 251 Complicated Ulcer 252 Uncomplicated Ulcer 253 Inflammatory Bowel Disease 256 Esophagitis/Gastritis/Miscellaneous Digestive Disease 257 Symptom/Sign of Digestive System 258 Other Gastrointestinal Disorder 360 Vertebral/Disc Disease 362 Arthritis 364 Back Pain/Strain 365 Pain/Stiffness, except Back 368 Orthopedic Aftercare 369 Strain/Sprain/Joint/Tendon Disorder 405 Cellulitis 406 Abscess

TECHNICAL NOTES


C 407 Other Disease/Disorder of Skin/Subcutaneous Tissue 408 Trauma of Skin/Subcutaneous Tissue/Breast 409 Non‐Malignant Breast Disorder 481 Other Disorder of Urinary System 482 Other Disorder of Kidney/Ureter 483 Disease/Disorder of Male Reproductive System 484 Symptom/Sign of Urinary System 485 Urinary Obstruction with Percutaneous Drainage 486 Urinary Obstruction without Percutaneous Drainage 488 Upper Urinary Tract Infection 521 Fibroid/Prolapse/Fistula/Other Disorder 524 Disorder of Menstruation/Endometriosis/Non‐inflammatory Disorder of Female Reproductive System 634 Hemoglobinopathy 637 Other Disease/Disorder of Blood/Lymphatic System 638 Chemotherapy/Radiotherapy Session for Neoplasm 639 Other Chemotherapy 661 Other/Unspecified Viral Illness 662 Fever 701 Psychoactive Substance Use, Withdrawal State 702 Psychoactive Substance Use, Withdrawal/Delirium 718 Non‐Extensive Burn 767 Other Fracture Dislocation of Leg 770 Other Fracture/Dislocation of Arm/Shoulder 775 Fracture of Skull/Facial Bone 776 Open Wound/Other/Unspecified Minor Injury 778 Poisoning/Toxic Effect of Drug 779 Concussion 781 Other/Unspecified Complication of Treatment 782 Post‐Operative Hemorrhage 783 Fracture/Dislocation of Wrist/Hand/Ankle/Foot 807 Prematurity and Growth Restriction, Age > 28 Days 813 Follow‐Up Treatment/Examination 815 Cancelled Intervention 993 Diagnosis Not Generally Hospitalized Surgical: 008 Other Site/Non‐Major Intervention on Spine/Spinal Canal/Vertebra 012 Open Carotid Endarterectomy 050 Orbit/Eyeball Intervention 074 Lymphatic Intervention with Ear/Nose/Throat Diagnosis 075 Larynx/Trachea Intervention with Ear/Nose/Throat Diagnosis 077 Partial Excision Musculoskeletal Tissue of Head 078 Other Musculoskeletal Intervention on Head 084 Sinus Intervention 086 Oral Cavity/Pharynx Intervention 114 Endoscopic Lung Resection 161 Implantation of Cardioverter/Defibrillator 169 Coronary Artery Bypass Graft with Cardiac Catheter without MI/Shock/Arrest without Pump 172 Coronary Artery Bypass Graft without Cardiac Catheter without MI/Shock/Arrest with/without Pump

TECHNICAL NOTES


C176 Percutaneous Coronary Intervention without MI/Shock/Arrest/Heart Failure 179 Cardiac Conduction System Intervention 185 Other/Miscellaneous Vascular Intervention 226 Non‐Major Excision/Repair of Upper Gastrointestinal Tract, Planned 227 Endoscopic Large Intestine/Rectum Resection without Colostomy 228 Complex Hernia Repair 229 Non‐Complex Hernia Repair 230 Repair/Fixation & Other Moderate Intervention on Lower Gastrointestinal Tract 232 Minor Lower Gastrointestinal Intervention 233 Complicated Appendectomy 234 Simple Appendectomy 235 Intervention on Anus Excluding Reconstruction 236 Simple Removal of Upper Gastrointestinal Foreign Body 278 Laparoscopic Cholecystectomy with/without Common Bile Duct Exploration 281 Extraction/Destruction of Calculus Common Bile Duct 302 Lower Limb Intervention with Flap/Graft with Malignant Neoplasm 304 Other Lower Limb Intervention with Malignant Neoplasm 312 C1/C2/Thoracic Spine Intervention 313 Spinal Vertebrae Intervention 317 Revised Hip Replacement without Infection 318 Revised Knee Replacement with Infection 319 Revised Knee Replacement without Infection 320 Unilateral Hip Replacement 321 Unilateral Knee Replacement 323 Open Knee Intervention except Fixation without Infection 324 Closed Knee Intervention except Fixation with Infection 325 Closed Knee Intervention except Fixation without Infection 326 Shoulder Replacement 327 Other Joint Replacement 331 Osteotomy of Lower Limb except Foot 332 Other Repair Bone of Leg except Ankle/Foot 333 Major Foot Intervention except Soft Tissue with Infection 336 Resection/Amputation/Fixation of Upper Limb except Shoulder/Hand 342 Biopsy/Invasive Inspection of Bone 343 Other Musculoskeletal Intervention except Soft Tissue 345 Soft Tissue Intervention of Lower Limb 347 Craniofacial Bone Intervention with Musculoskeletal Diagnosis 381 Minor Bone/Joint Intervention with Skin Diagnosis 382 Muscle/Tendon/Soft Tissue Intervention with Skin Diagnosis 384 Other Non‐Skin Intervention without Skin Graft 387 Unilateral Total/Radical Excision of Breast 388 Partial Excision Breast with Malignant Breast Diagnosis 390 Other Breast Intervention 392 Other Skin/Subcutaneous Tissue Intervention 421 Adrenal Gland Intervention 424 Thyroid/Parathyroid/Thymus Gland Intervention 450 Kidney Transplant 454 Major Intervention on Upper Urinary Tract 455 Minor Intervention on Upper Urinary Tract, Percutaneous Endoscopic Approach 456 Minor Intervention on Upper Urinary Tract, External/Per Orifice Approach 457 Major Intervention on Lower Urinary Tract

TECHNICAL NOTES


C 459 Non‐Major Intervention on Lower Urinary Tract, Planned 460 Major Intervention on Male Reproductive System 461 Non‐Major Intervention on Male Reproductive System 463 Partial Excision of Prostate, Open Approach 464 Partial Excision/Destruction of Prostate, Closed Approach 466 Intervention related to Dialysis, Planned Admission 501 Hysterectomy with Malignancy 502 Hysterectomy with Non Malignant Diagnosis 503 Fixation/Occlusion/Removal Intervention on Female Reproductive System except Tube/Ovary 505 Ovarian/Fallopian Tube Intervention with Non Malignant Diagnosis except Endoscopic Approach 507 Repair/Brachytherapy/Other Intervention on Female Reproductive System except Tube/Ovary 509 Therapeutic Intervention on Female Reproductive System, Laparoscopic Approach 512 Dilation & Curettage/Other Minor Intervention on Uterus 711 Non‐Extensive Burn with Skin Graft 728 Other Intervention on Hip/Lower Limb with Trauma/Complication of Treatment 729 Replacement/Fixation/Repair of Tibia/Fibula/Knee 736 Skin/Soft Tissue Intervention with Trauma with Flap/Graft 737 Skin/Soft Tissue Intervention with Trauma without Flap/Graft 738 Fixation/Repair of Shoulder Joint 739 Reduction/Fixation/Repair Upper Body/Limb except Fixation/Repair of Shoulder 740 Internal Fixation of Facial Bone 742 Ear/Nose/Throat Intervention with Trauma/Complication of Treatment 743 Other Intervention on Bone of Upper Body with Trauma/Complication of Treatment 744 Muscle/Tendon/Minor Joint Intervention with Trauma/Complication of Treatment, Lower Limb 745 Nerve Intervention with Trauma 747 Reduction/Fixation/Repair of Ankle/Foot 748 Other Intervention for Trauma/Complication of Treatment 749 Eye Intervention with Trauma/Complication of Treatment Exclusion criteria:

• Patients transferred to palliative care: Main patient service = 58 or service transfer = 58 or any diagnosis of “other aftercare” = Z51.5

• Patients transferred to an acute care facility‐ Transfer to facility = 1 • Patients with any code for trauma ICD‐10‐CA: S01^‐S03.3, S05.2‐S05.7, S06^‐S08^, S09.0, S09.2–

S09.9, S11^‐S13.3, S14.0‐S14.38, S15^, S17^‐S18, S21^‐S23.2, S24.0‐S24.28, S25^‐S28^, s29.7, S31^‐S33.4,S34.0‐S34.48, S35^‐S38^, S39.6‐S39.7, S41^‐S43.391, S45^, S46.00, S46.10, S46.20,S46.70, S46.80, S46.90, S47^‐S48^, S51^‐S53.1, S55^, S56.20, S56.50, S56.70, S56.80,S57^‐S58^, S61.2, S61.70‐S61.71, S61.80‐S61.81, S61.90‐S61.91, S62.000‐S62.001,S62.100‐S62.191, s62.200‐S62.291, S62.300‐S62.391, S62.400‐S62.401, S62.800‐S62.801,S63.000‐S63.091, S65^, S66.60, S66.70,S66.80, S66.90, S67^, S68.3‐S68.9, S71^‐S72^, S73.000‐S73.091, S75^, S76.00,S76.10, S76.20, S76.30, S76.40, S76.70, S77^‐S78^, S81^‐S82^, S83.000‐S83.3, S85^,S86.10, S86.20, s86.30, S86.70, S86.80,S86.90, S87^‐S88^, S91.00‐S91.01, S91.30‐S91.72, S92.000‐S92.301, S92.700‐S92.901,S93.000‐S93.111, S93.300‐S93.311, s95^,S97^, S98.0, S98.3‐S98.4, T01.00‐T01.91, T02‐T05, T06^, T08^, T09.1, T10^, 11.1‐T11.2,T11.4, T11.6, T12^, T13.1‐T13.2, T13.4, T13.6,T14.1‐T14.3, T14.5, T14.7, T20^‐T32^, T79^

• Patients with any code for cancer ICD‐10‐CA: C00^‐C43^, C45^‐C49^,C50^‐C97, Z51.0‐Z51.1, D00^‐D09^, D37^‐D48^

• Patients with an immunocompromised state (identified by procedure) CCI: 1.GT.85.LA‐XX‐J,

TECHNICAL NOTES


C1.GT.85.LA‐XX‐K,1.HY.85.LA‐XX‐K, 1.HZ.85.LA‐XX‐K, 1.HZ.85.LAXX‐L, 1.WY.19.HH‐XX‐A, 1.WY.19.HH‐XX‐I,1.WY.19.HH‐XX‐M, 1.PC.85.LA‐XX‐J, 1.PC.85.LAXX‐K, 1.OJ.83.WK‐XX‐A, 1.OJ.85.WK‐XX‐K,1.OJ.83.LA‐XX‐A, 1.OJ.85.GR‐XX‐K, 1.OJ.85.HAXX‐L, 1.OK.85^

• Patients with any code for an immunocompromised state (identified by diagnosis) ICD‐10‐CA: B24, B59, D80^‐D89^, T86.000,T86.001, T86.100‐T86.101, T86.200‐T86.201,T86.300‐T86.301, T86.400‐T86.401, T86.800‐T86.801, T86.810‐T86.811, T86.9, Z94.0‐Z94.4, Z94.80‐Z94.88



Data limitation: • This indicator, in its original form, was developed by Stanford University and the University of California under a contract with the Agency for Healthcare Research and Quality (AHRQ). CIHI/HayGroup adapted the methodology to a Canadian context for its Patient Safety Developmental Indicators Supplement to its Benchmarking reports. The first edition of the Supplement was released in August 2004.

• Each patient death in a low‐mortality CMG is flagged as a “sentinel event” and triggers a review of the patient’s chart, and where necessary, recoding of the chart. Due to this review procedure, there is a lag of 1 to 2 fiscal periods from the time a fiscal period has finished coding and the time the review and recoding process has been completed. For the periods shown, approximately 50% of the deaths were eventually excluded from the indicator as a result of recoding (i.e., regrouped in a non‐low‐mortality CMG or met an exclusion criterion). Due to the impact of the review process on the indicator result and the fact that corrections to the DAD are no longer being accepted by CIHI for fiscal years 02/03 and 03/04, the rates published in the benchmarking reports for these years will not coincide with those reported on the PHC BSC.

• The new CMG grouper and adjustments in the criteria was installed in January 2008 and cases from P1‐07/08 onwards were regrouped. This may have had some impact on the indicator result.

Target source: VCH


References: 1. http://www.qualityindicators.ahrq.gov/data/hcup/psi.htm2. 2003 Patient Safety Developmental Indicators Supplement, Benchmarking Comparison of Canadian

Hospitals. Hay Group/CIHI.

Notes: The methodology for this indicator is revised on an annual basis by CIHI, including the list of CMGs defined as low mortality.

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1.16. In‐hospital fracture rate per 1,000 patients aged 65 years and older Rationale: This indicator measures the extent to which we are engaging in processes to prevent or minimize the risk

of in‐hospital injuries for our patients aged 65 years and older.

Numerator: Number of discharges within the denominator, with the following criteria: Inclusion criteria: Number of discharges with at least one of the following diagnoses coded as a Type 2 diagnosis:

• S02^^ Fracture of skull and facial bones • S12^^ Fracture of neck • S22^^ Fracture of rib(s), sternum and thoracic spine • S32^^ Fracture of lumbar spine and pelvis • S42^^ Fracture of shoulder and upper arm • S52^^ Fracture of forearm • S62^^ Fracture at wrist and hand level • S72^^ Fracture of femur • S82^^ Fracture of lower leg, including ankle • S92^^ Fracture of foot, except ankle • T02^^ Fractures involving multiple body regions • T08^^ Fracture of spine, level unspecified • T10^^ Fracture of upper limb, level unspecified • T12^^ Fracture of lower limb, level unspecified • T142^^ Fracture of unspecified body region, closed

Exclusion criteria: • Minor fractures (including those of the teeth, fingers, and toes) • M966 Fracture bone following orthopaedic implant

Denominator: Total number of discharges aged ≥ 65 yearsInclusion criteria:

• Care level ACUTE Exclusion criteria:

• S02580 Fracture of tooth, closed • MCC 13 – obstetric discharges • MCC 14 – newborns and other neonates with conditions originating in the perinatal period




Target source: VCH (5% reduction from 2005/06 baseline)


References: ‐

Notes: ‐

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1.17. Influenza immunization rate for residents Rationale: This indicator measures the extent to which we are taking precautions to reduce the risk of influenza‐

related morbidity and mortality among residents.

Numerator: Number of residents who received an influenza vaccination

Denominator: Total number of residents*Note: The denominator is not adjusted for residents who refuse immunization


Data source: Residential care facilities (data is submitted to Infection Control for reporting)

Data limitation: • Currently, there are no standards for data collection for both the numerator and denominator: o There is an annual immunization “blitz”. Residents are also immunized if they are admitted

after the annual blitz. Some facilities included only those residents who were immunized during the blitz.

o For the denominator, some residential care facilities reported the total number of beds, others reported the number of residents at the time the data was collected.

• Data on immunization refusals began to be collected in FY 06/07. There are no data on refusals available for previous fiscal years.

Target source: Performance Agreement between the Ministry of Health Services and the Vancouver Coastal Health Authority

Comparator source: VCH *Note: VCH values include both the directly funded and the contracted facilities

References: Performance Agreement between the Ministry of Health Services and the Vancouver Coastal Health Authority. April 1, 2005 to March 31, 2006

Notes: ‐

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1.18. Influenza immunization rate for staff Rationale: This indicator measures the extent to which we are taking precautions to reduce the risk of influenza

transmission to residents and patients and reduce the risk of absenteeism due to illness in staff.

Numerator: The number of full‐time, part‐time, and casual staff who received an influenza immunization

Denominator: Total number of full‐time, part‐time, and casual employees at the time of the annual immunization campaign Exclusion criteria:

• Staff who have already been immunized (e.g. at their doctor’s office or other place of work) • Employees on LTD • Non‐employees whose pay is managed by PHC (Paymasters) • Physicians and contracted services employees


Data source: ESP & PeopleSoft

Data limitation: • Data may not be directly comparable between fiscal years due to changes in data collection procedures.

• VCH values include both the directly funded and the contracted facilities. The definition of the health care workers at VCH includes contracted staff and physicians, whereas PHC excludes them.

Target source: Performance Agreement between the Ministry of Health Services and the Vancouver Coastal Health Authority



Notes: • FY09/10 data includes people who have been immunized for either influenza or H1N1 or both. • PHC revised its Influenza Immunization Policy for staff in October 2008 to include follow‐up provisions

for non‐immunized staff.

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1.19. % oncology patients receiving surgery within targeted times Rationale: This indicator measures the responsiveness of the health system to the needs of the population.

Numerator: Number of patients from denominator who had surgery within targeted wait time

Denominator: Number of patients who had surgery Exclusion criteria: Excluded are OR rooms: endoscopy clinic (SJENDO, SPHENDO1, SPHENDO2, SPHENDO3, SPHRAD1, SPHRAD2, SPHGIMOT, SPHGIER, SPHGIWL), cystoscopy clinic (SVHCYS), non‐surgical OR/PAR (SVHFLEX, SPHFLEX), Inclusion criteria: • Cases with oncology flag • Scheduled cases only • Service name is OPHTHALMOLOGY, ORAL MAXILLOFACIAL, ORTHOPEDIC, OTOLARYNGOLOGY,

PLASTIC, THORACIC for the cases that are based on Procedure code. • Service name is GYNECOLOGY, UROLOGY, GENERAL, VASCULAR for the cases that are based on

Diagnosis code. *Notes: • Wait times for surgery are measured from the date of receipt of booking card. • Oncology flag:

For procedure‐based cases, the oncology case is being identified by a Health Records coder that assigns the flag, as well as the pre‐defined oncology flag (from the target table), that is based on the procedure code. For diagnosis‐based cases, the oncology cases are being identified only by the pre‐defined oncology flag that is based on the diagnosis code, without considering the health records flag assigned by a coder.


Data source: ORMIS, Health Records


Target source: There are two target tables (based on Procedures and Diagnosis) that were developed and are updated by the Surgical Business Committee. In the future, we will be moving towards diagnosis‐based targets exclusively, once the system and education is in place. • Depending on service (see Inclusion criteria), the target is based on the procedure code (target table is

linked on procedure code) AND on the diagnosis code (target table is linked on diagnosis code and service).

• There was a change in the target in 06/07‐11, therefore different target tables are used for the data before this period.


References: ‐

Notes: ‐

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1.20. % ALC census days Rationale: This indicator measures the extent to which patients are in the appropriate care setting and the extent

to which the community is able to respond to the needs of patients waiting in hospitals for further care/accommodation in alternate care settings.

Numerator: The inpatient census days with care level of ALC (Alternate level of care) or LTC (Long term care)

Denominator: The inpatient census days with care level of ACUTE, EMER, ALC or LTC*Note: In the Census data, the days with EMER carelevelcode have patient type of OUTPATIENT. However, we do include them as inpatient days as the logic suggests backdating the inpatient days.


Data source: Access Manager

Data limitation: • The way in which ALC designation has occurred in PHC acute and rehab sites has changed over time. When ALC designation and data collection commenced in PHC hospitals in 1998 following a ministerial mandate, there were no explicit criteria provided by CIHI to guide the ALC designation process and thus resulted in multiple and often conflicting interpretations of the definition of ALC. Therefore, the application of the InterQual acute and subacute criteria sets in determining ALC status commenced:

o December 2003 – PHC began piloting the application of InterQual in determining ALC status on 4 Medicine nursing units at MSJ and SPH.

o January 2005 – The Transition Services Team (TST) of Vancouver Community began assuming the responsibility for ALC designation at PHC’s acute and acute rehab sites. By March 31, 2005, the TST had been implemented on all inpatient units across PHC with the exception of HFH rehab and psychiatric units at SPH.

o May 2005 – The TST was implemented at HFH rehab. o May 2006 – The TST began piloting the use of the InterQual mental health criteria on

psychiatric units. By April 2007, the criteria had officially been adopted in determining ALC status on psychiatry units.

Target source: VCH

Comparator source: Vancouver Acute/Community – VCH Census Cubes

References: ‐

Notes: Alternate Level of Care (ALC) (definition): A designation given to a patient whose acute and subacute phase of inpatient treatment has ended but who still remains in an acute care bed.

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1.21. Proportion of ED patients seen by provider within targets Rationale: This indicator measures the extent to which ED patients are able to access appropriate assessment and

treatment in a timely manner.

Numerator: Number of Emergency cases whose TRIAGE time to the time they are SEEN BY first care provider (Physician, Psych.CNL, Med. Resident, Med. Student) is within the recommended time:

• CTAS Level 2 – 15 minutes or less; and • CTAS Level 3 – 30 minutes or less

Denominator: Total number of Emergency cases for CTAS levels 2 and 3 Exclusion criteria:

• Patients with MISSING time seen by first care provider or missing triage time • Patients with INVALID records (as defined in the filter applied in July 2009 by ADS) • Patients with missing FACILITY code




Target source: VCH

Comparator source: Vancouver Acute – VCH

References: ‐

Notes: Canadian Emergency Department Triage & Acuity Scale (CTAS) is a tool that enables Emergency Departments to prioritize patient care requirements and to examine patient care processes, workload, and resource requirements relative to case mix and community needs.

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1.22. % admitted patients leaving ED within 10 hours of triage Rationale: This indicator measures the extent to which patients in our EDs receive care in a timely manner as well

as patient flow through the system as defined by the transit time targets from the ED Pay for Performance (EDP) initiative.

Numerator: Number of admitted patients who LEFT ED within 10 hours of their TRIAGE time

Denominator: Number of admitted patients that left ED (see Notes)Exclusion criteria: • Patients with MISSING triage time • Patients with INVALID records (as defined in the filter applied in July 2009 by ADS) • Patients with missing FACILITY code



Data limitation: For mental health admitted patients, since July 25, 2008 (start of P5‐08/09), the Comox Quiet Room (CQRM) is considered an inpatient mental health unit. Prior to this, CQRM was considered part of Emergency Room.

Target source: Regional EDP target


References: ‐

Notes: Inpatient cases who left ED are defined as follows: Inpatient cases that were admitted from ED and 1) Transferred to an Inpatient unit or 2) Discharged from ED (usually these cases are admitted to Acute care but stay in the ED).

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1.23. % acute LOS (length of stay) compared to ELOS (expected length of stay)

Rationale: This indicator informs us how PHC length of stay compares with that of our national peer hospitals, represented by ELOS.

Numerator: Sum of actual acute portion of LOS for inpatient cases discharged within time period Exclusion criteria:

• Newborn/stillborn cases • Atypical cases • Acute rehabilitation cases (HFH) (up until P11‐08/09) • ALC days

Denominator: Sum of ELOS for inpatient cases discharged within time periodExclusion criteria:

• Newborn/stillborn cases • Atypical cases • Acute rehabilitation cases (HFH) (up until P11‐08/09)



Data limitation: • In December 2002, CIHI suspended the use of the complexity overlay as a refinement to the CMG methodology. Data quality studies conducted by CIHI have concluded that variations in coding practices render the use of the complexity overlay unreliable for comparative purposes. After consulting with stakeholder groups, the decision was made to retain complexity overlay until a revised ICD‐10‐CA/CCI‐based methodology can be introduced (fiscal year 2005/06).

• Due to the introduction of the new ICD‐10‐CA diagnostic classification system, many problems have arisen related to the grouping of cases into Case Mix Groups (CMGs). These issues affect fiscal years 01/02, 02/03, and 03/04. In June 2004, Health Records data for these years was regrouped after the installation of the new 3M CMG grouper.

• The new CMG grouper was installed in February 2005 and cases from FY 01/02 onwards were regrouped. This may have had some impact on the indicator result.

Target source: VCH

Comparator source: VCH DAD cube

References: ‐

Notes: • Expected length of stay (ELOS) (definition): A predicted LOS for a typical CMG. Each complexity level and age group within a CMG has its own unique ELOS value.

• Since the switch to a virtual single site, visits discharged from HFH have not been excluded since this would exclude cases that also spend part of their stay in SPH or MSJ. The effect on PHC ALOS/ELOS is minimal. The program most affected is the Elder Care Program, whose ALOS/ELOS is significantly higher. An evaluation of the impact of the virtual single site on indicators such as ALOS/ELOS is pending.

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1.24. Cost per weighted case Rationale: The cost per weighted case provides a measure of the average financial cost a facility incurs to treat a

single patient.

Numerator: The operating costs for a specific set of functional centres (patient transport, patient food services, inpatient nursing, ambulatory care, and diagnostic & therapeutic services) excluding medical staff compensation, equipment acquisition, building amortization and rent

Denominator: Total number of inpatient weighted cases

Calculation: numerator/denominator

Data source: Hay Group

Data limitation: • Unlike some provincial approaches (such as used in Ontario), it does not include day surgery costs or activity. Nor does it include any cost/activity factors for long term care activity.

Target source: ‐


References: Hay Group Benchmarking Comparison of Canadian Hospitals 2009, Operational Efficiency Methodology Manual, December 2009.

Notes: • Weighted cases have been grouped to the same CMG grouping methodology (09/10); however, costs are unadjusted from year to year.

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1.25. Cumulative net surplus (deficit) Rationale: This indicator measures the extent to which PHC is meeting its budget plan.

Numerator: Cumulative year‐to‐date net surplus (deficit) after retirement allowances

Denominator: ‐

Calculation: ‐

Data source: Finance (V&E report)


Target source: PHC’s cumulative year‐to‐date budgeted net surplus (deficit) after retirement allowances

Comparator source: VCH – Volume and Efficiency (V&E) Report

References: ‐

Notes: ‐

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1.26. Administrative and support costs as % of total expenses Rationale: The Ministry of Health Services Performance Agreement of 2002/03 set a performance expectation of a

reduction in annual expenditures for Support and Administrative Services by at least 7% of the costs incurred for the fiscal year 2001/2002, by the 2004/2005 fiscal year.

Numerator: Administration and support costs

Denominator: Total expenses (including retirement allowance)


Data source: BC Ministry of Health Services

Data limitation: • Data has been restated back to FY 03/04 to remap accounts under the current Ministry definition. • During FY 06/07 certain Referred Out accounts were removed from inclusion under Administrative and

Support costs resulting in lower costs as a % of total expenses across all health authorities.

Target source: ‐

Comparator source: VCH (excluding PHC and Louis Brier Home) ‐ BC Ministry of Health Services


Notes: ‐

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1.27. % sick hours Rationale: This indicator measures the extent to which PHC employees are absent due to illness.

Numerator: Number of paid sick hours

Denominator: Total number of productive hours


Data source: Finance


Target source: VCH


References: ‐

Notes: Productive hours (definition): Total actual hours worked including regular, overtime, workload and absence relief, and excludes premium

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1.28. % overtime hours Rationale: This indicator measures the extent to which overtime workload is placed on PHC employees.

Numerator: Number of overtime hours

Denominator: Total number of productive hours


Data source: Finance


Target source: VCH


References: ‐

Notes: • Overtime hours (definition): Total actual hours worked overtime • Productive hours (definition): Total actual hours worked including regular, overtime, workload and

absence relief, and excludes premium

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1.29. Productive nursing hours per patient day (RN, LPN) Rationale: This indicator measures the actual productivity against the budget, which are the standards set out by

Nursing Practice. The standards ensure that there are adequate levels of direct care hours in place

Numerator: Productivity nursing hours: staff worked hours that relate directly to patient care or being "on the job"• Worked on Regular day • Relief • Overtime • Worked on Stat day

(Everything else is Non‐Productive hours: staff paid hours that do not directly relate to patient care or being "on the job":

• Sick • Vacation • Stat day off • Education & Training • Injury • Other Paid Leave)

Denominator: Patient Days: based on census daysInclusion criteria:

• Included are cost centres that have beds

Calculation: numerator/denominator

Data source: Finance Reports


Target source: ‐


References: ‐

Notes: Poor performance is when the actual are higher than budget. While periodic fluctuations are ‘normal’, continual poor performance needs to be addressed.

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2.1. % positive responses to survey items related to Spirituality Rationale: This indicator measures the extent to which we live the PHC values as measured by the experiences of

the people we serve and the people who serve.

Numerator: Number of positive responses to the following survey items:• Acute inpatient: Yes, completely • ER: Yes, completely • Ambulatory oncology: Yes, completely • Resident: Yes • Staff: Agree + Strongly Agree

Denominator: Total number of nonblank responses to the following survey items: • Acute inpatient: “Were your spiritual needs met?” for those who also responded “Yes” to item:

“Do you feel your spiritual needs are an important part of your overall care?” • ER: “Were your spiritual needs met?” for those who also responded “Yes” to item: “Do you feel

your spiritual needs are an important part of your overall care?” • Ambulatory oncology: “Were your spiritual needs met?” for those who also responded “Yes” to

item: “Do you feel your spiritual needs are an important part of your overall care?” • Resident: Are your spiritual or religious needs met here? • Staff: PHC promotes the emotional and spiritual well being of staff and patients


Data source: • Acute inpatient: NRC Picker Acute Inpatient Satisfaction Survey • ER: NRC Picker Emergency Department Patient Satisfaction Survey • Ambulatory oncology: NRC Picker Outpatient Cancer Care Experience of Care Patient Survey • Resident: NRC Picker Long Term Care Resident Survey • Staff: Gallup Employee Engagement Survey

Data limitation: The patient and resident surveys are commissioned by the Ministry of Health and the health authorities. Therefore, PHC does not have direct influence on the frequency and timing of the surveys.

Target source: PHC Mission Indicators Working Group


References: ‐

Notes: ‐

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2.2. % positive responses to survey items related to Integrity Rationale: This indicator measures the extent to which we live the PHC values as measured by the experiences of

staff.

Numerator: Number of positive responses: Agree + Strongly Agree

Denominator: Total number of nonblank responses to the question: The values of PHC impact how decisions are made where I work.


Data source: Gallup Employee Engagement Survey

Data limitation: • The staff survey methodology has changed. Prior to 2007, staff were surveyed at the Living the Mission Workshops (approximately 300 responses). As of 2007, staff feedback is obtained from the Employee Engagement Survey administered to PHC employees in October 2007 (approximately 2300 responses). There are survey items that are either under development or are being pursued for addition to the existing surveys.



References: ‐

Notes: ‐

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2.3. % positive responses to survey items related to Trust Rationale: This indicator measures the extent to which we live the PHC values as measured by the experiences of


Numerator: Number of positive responses to the following survey items:• Acute inpatient: Yes, always • ER: Yes, always • Ambulatory oncology: Yes, always • Staff: Strongly + Very Strongly

Denominator: Total number of nonblank responses to the following survey items: • Acute inpatient:

o Do you have the confidence and trust in the doctors treating you? o Do you have confidence and trust in the nurses treating you?

• ER: o Do you have the confidence and trust in the doctors treating you? o Do you have confidence and trust in the nurses treating you?

• Ambulatory oncology: o Do you have the confidence and trust in the doctors treating you? o Do you have confidence and trust in the nurses treating you?

• Staff: o I have confidence and trust in the people with whom I work.






References: ‐

Notes: ‐

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2.4. % positive responses to survey items related to Respect Rationale: This indicator measures the extent to which we live the PHC values as measured by the experiences of


Numerator: Number of positive responses to the following survey items:• Acute inpatient: Yes, always • ER: Yes, always • Ambulatory oncology: Yes, completely • Staff: Agree + Strongly Agree

Denominator: Total number of nonblank responses to the following survey items: • Acute inpatient: Did you feel like you were treated with respect and dignity while you were in the

hospital? • ER: Did each hospital staff person treat you with respect and dignity? • Ambulatory oncology: Did your care providers treat you with dignity and respect? • Staff: Average of these two questions:

o At work, I am treated with respect. o Differences among individuals are respected and valued.






References: ‐

Notes: ‐

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3.1. Resident family overall quality rate Rationale: This indicator measures the extent to which residents of PHC residential care facilities are satisfied with

the care and service that is being provided to them

Numerator: Number of positive responses for each of the survey questions specified under Denominator:• Overall Quality: Good + Very Good + Excellent • Resident Needs: Good + Very Good + Excellent • Dignity: Good + Very Good + Excellent • Tender Loving Care: Good + Very Good + Excellent • Likely to Recommend: Probably Recommend + Definitely Recommend

Denominator: Total number of responses for each of the following survey questions:• Overall Quality: Overall, how would you rate the quality of care and services provided? • Resident Needs: How would you rate the facility at taking care of your family member's needs? • Dignity: How would you rate the facility at maintaining your family member's dignity? • Tender Loving Care: How would you rate the staff at providing tender, loving care? • Recommend to Others: If this type of care were required for another family member or friend,

would you recommend this facility?


Data source: NRC Picker Long Term Care Family Experience Survey


Target source: VCH Residential Care Performance Measurement Framework

Comparator source: Comparator represents the average score across Canadian sites in the 2008 database

References: Providence Health Care – Long Term Care Resident Evaluation Survey. Resident Results January 2000. Prepared by Smaller World Communications Inc.

Notes: ‐

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3.2. ED patient satisfaction Rationale: This indicator measures the extent to which patients visiting PHC’s EDs are satisfied with the care and

service that is being provided to them.

Numerator: Mean of total responses for the ED patient satisfaction survey question: “Overall, how would you rate the care you received in the Emergency Department?” on the scale 1 to 5, where 1=poor, 2=fair, 3=good, 4=very good, 5=excellent

Denominator: ‐

Calculation: ‐

Data source: NRC Picker Emergency Department Patient Satisfaction Survey

Data limitation: Patients seen in the Emergency Departments at SPH and MSJ are randomly sampled to provide information about their experience of care at these sites and statistical sampling approaches are used to ensure a representative sample. The proportion of patients presenting to the SPH ED with no fixed address is compensated for in the development of sample plans, however, these patients’ views are NOT included in the results, as surveys use a mail delivery method. Similarly, the proportion of patients who are non‐English speaking, especially at MSJ are offered alternate language surveys, however, response rates should be reviewed to determine if a representative sample has been achieved.

Target source: ‐

Comparator source: NRC Picker Emergency Department Patient Satisfaction Survey

References: ‐

Notes: The results are taken from the “BC ED Patient Experience – Monthly and Bi‐Monthly Results Reports”

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3.3. Acute inpatient satisfaction rate Rationale: This indicator measures the extent to which inpatients are satisfied with the care and service that is

being provided to them.

Numerator: Number of positive responses for each of the questions/dimensions specified under Denominator:• Overall Quality: Good + Very Good + Excellent • Access to Care: Varies by survey question • Respect for Patient Preferences: Varies by survey question • Physical Comfort: Varies by survey question • Continuity & Transition: Varies by survey question • Information & Education: Varies by survey question • Emotional Support: Varies by survey question • Involvement of Family: Varies by survey question • Coordination of Care: Varies by survey question • Likely to Recommend: Yes, Definitely + Yes, Probably

Denominator: Total number of responses for each of the following survey questions/dimensions: • Overall Quality: Overall, how would you rate the care you received at the hospital? • Access to Care: Comprised of several specific survey questions. • Respect for Patient Preferences: Comprised of several specific survey questions. • Physical Comfort: Comprised of several specific survey questions. • Continuity & Transition: Comprised of several specific survey questions. • Information & Education: Comprised of several specific survey questions. • Emotional Support: Comprised of several specific survey questions. • Involvement of Family: Comprised of several specific survey questions. • Coordination of Care: Comprised of several specific survey questions. • Likely to Recommend: Would you recommend this hospital to your friends and family?


Data source: NRC Picker Acute Inpatient Satisfaction Survey


Target source: ‐


References: ‐

Notes: The comparator represents the average score across all Canadian sites in the survey database.

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4.1. Overall engagement rate Rationale: This indicator uses the Gallup Q12 survey as a means to measure the extent to which staff is engaged.

Research (Gallup) shows that engagement is directly correlated to success in business outcomes such as productivity, staff retention, patient and staff safety, and customer/patient satisfaction.

Numerator: Grand mean of the Q12 in the employment engagement survey to the PHC employees

Denominator: ‐

Calculation: ‐

Data source: Gallup Employee Engagement Survey


Target source: Gallup Employee Engagement Survey


References: ‐

Notes: ‐

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4.2. Difficult to fill vacancy rate Rationale: Difficult to fill positions are those that have been vacant for more than 90 days. The vacancy rate of

these positions identifies areas where PHC is having difficulty in hiring. This indicator has been modified to match the Ministry definition.

Numerator: Count of vacancies of 1) Nurse and 2) Allied health positions, at fiscal period end date, that have been vacant for more than 90 days since posted

Denominator: Numerator + Count of filled positions at fiscal period end date• Filled positions are defined as Employee job count where ‐

1. Job indicator = Primary (Employee owns the position) 2. Job Status = Regular 3. Employee status is non‐terminated (Includes employees on leave other than LTD and ex‐LTD)


Data source: Human Resources


Target source: BC Government Letter of Expectations


References:

Notes: • NURSES: those belonging to the NBA, which stands for Nursing Bargaining Association (Labour Agreement) that includes both ‐ BCNU (RNs) and HSA (RPNs) Nurses.

• ALLIED HEALTH: those belonging to the HSPBA which is the Health Sciences Professional Bargaining Association (Labour Agreement).

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4.3. External turnover rate (regular employees) Rationale: This indicator measures the rate of terminations from the organization. It reflects the extent to which we

can retain employees.

Numerator: Count of terminations during the fiscal period

Denominator: Number of regular employees at the start of fiscal period + regular hires during the fiscal period

Calculation: (numerator/denominator)*annualizing factor*100*Note: Annualizing factor=365/number of days in the fiscal period

Data source: Human Resources


Target source: ‐


References: ‐

Notes: Turnover results in various costs due to having to recruit constantly. Direct costs relate to advertising, hiring, training and transactions. Indirect costs include impact on productivity, service levels and morale as the system is put under pressure.

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4.4. Worksafe BC MSI (musculoskeletal injury) incidence rate for direct care areas

Rationale: This indicator measures the extent to which PHC is providing a safe working environment for its direct care employees.

Numerator: Number of approved Worksafe BC (WSBC) claims for time‐loss musculoskeletal injuries for direct care area cost centres (see Denominator for list of cost centres) Inclusion criteria:

• Musculoskeletal injuries correspond to any of the following codes in the Attributes field in the Parklane System:

o Musculoskeletal injury o Sprain/strain o Tendonitis o Carpal tunnel o Overexertion – weight o Overexertion – effort

• Approved claims include those claims whose Claim Status is: o Approved o Blank or Pending AND have associated claims costs

Denominator: Number of productive hour FTEs (1 FTE = 1,875 productive hours) for direct care area cost centresInclusion criteria:

• The following cost centres constitute direct care areas: Diagnostics: 7405000040 Radiology Nursing 7415400040 Nuclear Medicine 7415100035 Diagnostic Imaging RIS 7415550040 Cardiac Catheterization Lab 7415100040 Diagnostic Imaging RIS 7415700040 Magnetic Resonance Imaging 7415180035 Radiology 7415700140 MRI Magnet 7415180038 Radiology 7415990031 Diagnostic Imaging 7415180040 Radiology 7425100040 Electroencephalography (EEG) 7415180140 Diagnostic Imaging 7425200040 Electromyography (EMG) 7415230040 Vascular Angiography 7430202040 Echocardiography 7415250035 Computed Tomography 7430208040 Electrophysiology 7415250040 Computed Tomography 7430209040 Electrocardiography (ECG) 7415300035 Ultrasound 7430400040 Vascular Diagnostic Laboratory 7415300040 Ultrasound Inpatient: 7120990635 General Float Pool 7230000240 Nursing Casual Float Pool 7135406031 Sterile Processing Department 7230000431 3 East Medical Nursing Unit 7135406035 Sterile Processing Department 7230000435 3 East Medical Nursing Unit 7135406038 Sterile Processing Department 7230000635 DT Procedure Rooms 7135406040 Sterile Processing Department 7230000731 Nursing Floors General 7180600040 Emergency Admitting 7230000935 GATU 7182100040 Access Services 7230001040 Resource Centre 7205100240 Nursing Shortage 7230001140 GRU‐RUFF 7205100340 Nursing Council 7230001235 Surgery‐Medicine Relief 7210100035 Medical Nursing Unit 7240300031 Intensive Care Unit 7210100040 Medical Nursing Unit 7240300035 Intensive Care Unit 7210100140 Medical Nursing Unit 7240300040 Intensive Care Unit 7210100240 Medical Nursing Unit HUB 7240300140 Critical Care Relief (SPH) 7210100440 Medical Nursing Unit Geri‐Rehb 7240400040 Cardiac Surgery ICU 7210100640 Fam Prac,Geri Psyc 10C 7240450040 Coronary Care Unit 7210100740 Medical Nursing Unit ‐ 7AB 7250802040 Special Care Nursery 7210100840 Medicine Relief (SPH) 7250900040 Maternity‐Delivery 7210450040 Med Unit ‐ Resp,Fam Pract 7250900140 Delivery Room 7210700040 Nephrology,Urology (6B) 7260000240 Surgery Relief SPH

TECHNICAL NOTES


C7220100031 Surgical Nursing Unit 7260200031 Operating Room 7220100035 Surgical Nursing Unit 7260200035 Operating Room 7220100140 Surgical Nursing Unit 7260200040 Operating Room 7220100240 General Surgery 9A 7260200140 OR ‐ Cardiac 7220200040 Orthopedic Nursing Unit 7265200031 Post Anaesthesia Recovery Unit 7220200131 Geriatric Orthopedc Rehab Unit 7265200035 Post Anaesthesia Recovery Unit 7220402040 Cardiology Nursing Unit 7265200040 Post Anaesthesia Recovery Unit 7220402140 Heart Surgery Nursing Unit 7270990035 Paediatric Nursing Unit 7220750040 Urology Nursing Unit (6B) 7275201031 Geriatric Psych Inpatient 1 7230000131 GRU‐GATU 7275201231 Geriatric Psych Inpatient 2 7230000140 GRU‐GATU 7275201235 Geriatric Psych Inpatient 2 7275201340 Eating Disorders Inpatient 7340853040 Home Hemodialysis 7275201540 Psych Acute Long Stay 7350107540 Chronic Pain Program 7275201640 Psych Acute General (9A) 7435600040 Perfusion 7275350040 Psych Acute Short Stay 7445000031 Clinical Nutrition 7280100038 General Rehab Nursing Unit 7445000035 Clinical Nutrition 7280100040 General Rehab Nursing Unit 7445000038 Clinical Nutrition 7290000040 Palliative Care 7445000040 Clinical Nutrition 7290000140 Windermere Lodge Hospice 7470105031 Social Work 7307001640 Hematology CASC 7470105035 Social Work 7310200035 General Emergency 7470105040 Social Work 7310200040 General Emergency 7470105238 Social Work IP 7310250031 Urgent Care Outpatient: 7195990140 Diabetes Nutrition Services 7350108040 Foot and Ankle Clinic 7205202040 Intravenous Therapy (9B) 7350108740 Cystic Fibrosis Specialty Clin 7210100340 Eating Disorders Community Prj 7350109540 Kidney Function Centre 7210310031 SARS Clinic 7350152540 Ear Nose and Throat Specialty 7210310040 SARS Clinic 7350154540 Pre‐Admission Clinic 7230000835 Geriatric Unit 7350155540 Cardiac Transplant Clinic 7305000040 Eating Disorders Resource Ctr 7350155640 Renal Transplant Clinic 7340100040 Medical Short Stay Unit 7350170040 Ambulatory Care 7340200031 Surgical Day Care 7350170140 Rapid Access Clinic 7340200035 Surgical Day Care 7350201040 Heart Function Clinic 7340200040 Surgical Day Care 7350203040 Pacifc Adlt Congenitl Hrt Clin 7340200140 SDC ‐ Private Clinic Referrals 7350204040 Pacemaker Clinic 7340352040 CIU,Cardiac Short Stay (5CD) 7350206040 Cardiac Rehabilitation Clinic 7340500040 Diabetes Clinic 7350502040 Maternity Education Program 7340500140 Diabetic Weekend Clinic 7350601040 Ophthalmology Clinic 7340602031 Geri‐Day Hospital 7350652031 Falls and Fracture Clinic 7340602135 Geri‐Day Hospital 7350652040 Falls and Fracture Clinic 7340602240 Geriatric Outpatient Clinic 7350801040 General Outpatient Psychiatry 7340604031 Geriatric Outreach 7350807040 Eating Disorders Clinic 7340604140 Elder Care Central Intake 7350990035 Multi‐Purpose Amb Care 7340851340 Comm Dialysis ‐ Sechelt 7470105338 Social Work OP 7340851440 Comm Dialysis ‐ Vancouver 7470200040 Domestic Violence 7340851540 Hemodialysis Unit 7510802040 HOME ENTERAL NUTRITION 7340851640 Comm Dialysis ‐ Richmond 7510802140 HOME PARENTAL NUTRITION 7340851740 Comm Dialysis ‐ Squamish 7510802240 HEMOSIDIEROSIS 7340851840 Comm Dialysis ‐ Powell River 7510802340 HEMOPHILIA 7340851940 Comm Dialysis ‐ North Shore 7515500035 Lifeline 7340855040 Peritoneal Dialysis Unit 7515500038 Lifeline 7350101540 Infectious Diseases Clinic 7532300040 Home IV Antibiotic Pgm 9B 7350105040 GI Clinic 7532300140 Home IV ‐ Closer to Home 7350108031 Foot and Ankle Clinic Rehabilitation Services: 7350851038 General Rehabilitation Clinic 7455205035 Occupational Therapy 7435259935 Respiratory Services 7455205040 Occupational Therapy 7435259935 Respiratory Services 7455205238 Occupational Therapy IP 7435259935 Respiratory Services 7455205338 Occupational Therapy OP 7435259940 Respiratory Services 7460200038 Communication Disorders 7450005031 Physiotherapy 7460200038 Communication Disorders 7450005035 Physiotherapy 7460200038 Communication Disorders

TECHNICAL NOTES


C 7450005040 Physiotherapy 7460200040 Communication Disorders7450005238 Physiotherapy IP 7460400040 Audiology 7450005338 Physiotherapy OP 7485000040 Recreation Therapy 7455205031 Occupational Therapy 7485000238 Recreation Therapy 7455205035 Occupational Therapy 7485100031 Music Therapy Residential Care: 7185400032 Inter‐Hospital Transport 7295201232 Residential Care ‐ Chronic 3 7185404031 External Patient Transport 7295201335 Residential Care Relief 7185404032 External Patient Transport 7295300036 Residential Care ‐ Multilevel 7185404033 External Patient Transport 7450005032 Physiotherapy 7185404034 External Patient Transport 7450005033 Physiotherapy 7185404035 External Patient Transport 7450005034 Physiotherapy 7295201031 Residential Care ‐ Chronic 1 7450005036 Physiotherapy 7295201032 Residential Care ‐ Chronic 1 7450005138 Physiotherapy ECU 7295201033 Residential Care ‐ Chronic 1 7455205032 Occupational Therapy 7295201034 Residential Care ‐ Chronic 1 7455205033 Occupational Therapy 7295201035 Residential Care ‐ Chronic 1 7455205034 Occupational Therapy 7295201038 Residential Care ‐ Chronic 1 7455205036 Occupational Therapy 7295201132 Residential Care ‐ Chronic 2 7455205138 Occupational Therapy Res 7295201134 Residential Care ‐ Chronic 2 7470105032 Social Work 7295201135 Residential Care ‐ Chronic 2 7470105033 Social Work 7295201138 Residential Care ‐ Chronic 2 7470105034 Social Work 7470105036 Social Work 7485000138 Recreation Therapy Res 7485000034 Recreation Therapy 7485100032 Music Therapy 7485000035 Recreation Therapy 7485100035 Music Therapy Support Services: 7185200035 Porters 7480000035 Pastoral Care 7185200040 Porters 7480000036 Pastoral Care 7480000030 Pastoral Care 7480000038 Pastoral Care 7480000031 Pastoral Care 7480000040 Pastoral Care 7480000032 Pastoral Care


Data source: Parklane System & Finance

Data limitation: • Concerns have been raised about the quality of the data captured by the Parklane System. Further investigation is required to assess data quality.

• Data were restated in 2006 due to data quality issues related to the Claim Status field. Not all approved claims are coded as such in this field thus a claim was previously considered approved if the claim status field = Approved, Pending, or Blank. The definition of an approved claim was revised to consider as approved: all claims coded as Approved, and claims coded as Pending or Blank with costs associated with them.


Comparator source: VCH Employee Engagement Cubes

References: ‐

Notes: • Musculoskeletal injury (MSI) – Includes all injuries as a result of strains or sprains, overexertion, repetitive movements, tendonitis, and carpal tunnel syndrome that result in time loss.

• Direct care area – Any cost centre where the staff members have, as their primary role, interaction with patients, residents or clients.

TECHNICAL NOTES


C

4.5. Worksafe BC experience rating adjustment Rationale: This indicator measures the extent to which PHC has been able to maintain a safe working environment

for its employees relative to the rest of the provincial acute care sector.

Numerator: Worksafe BC (WSBC) experience rating adjustment

Denominator: ‐

Calculation: ‐

Data source: Payroll

Data limitation: Prior to 2008, PHC's acute care and residential care sites were grouped under the Acute Care classification unit. In 2008, PHC was reclassified into 4 different rate groups: acute care, residential care, rehabilitation care, and community health support.

Target source: WSBC base rate for the classification unit

Comparator source: VGH/UBC

References: ‐

Notes: • The indicator includes only the Acute care and Long Term care as they comprise 95% of PHC's total assessable earnings. Since experience rating adjustments are based on 3 years of injury claims, PHC's adjustments for its new classification units were based on one year of claims history.

• Experience rating adjustment (definition): The discount/surcharge applied to an employer’s base rate based on the employer’s injury costs relative to the industry average (up to a maximum discount of 50% and a maximum surcharge of 100%)

• Base rate (definition): The amount charged per $100 of assessable earnings. The same base rate applies for all employers within the same classification unit, or industry (i.e., Acute Care).

TECHNICAL NOTES


C

5.1. Total annual research funding Rationale: This indicator measures the extent to which PHC has been able to secure new research funding as

compared to the previous fiscal year(s).

Numerator: Total research funding by the following funding categories:• Clinical sponsored research (CT &IICT) • Industry & government contracts and agreements • MSFHR funds • CFI, BC KDF and matching funds • Grants, other (includes personnel awards) • Peer‐reviewed grants

Denominator: ‐

Calculation: ‐

Data source: UBC RISe database

Data limitation: • This funding information should be interpreted as approximate only. Office of Research Services, Industry Liaison (ORSIL) did not capture all grant funding and thus total research funding is underreported. There are known omissions in the data reported. For example, ORSIL did not capture any graduate student salaries in 00/01 or 01/02. Data reported for 02/03 is more accurate than previous fiscal years, although some grant funding may be missing and/or underreported.

• Clinical trials funding could not be broken out for FY 00/01 and FY 01/02 and thus these dollars are subsumed under the other funding categories for those fiscal years.

Target source: ‐


References: ‐

Notes: • CFI: Canadian Foundation for Innovation • BCKDF: BC Knowledge Development Fund • MSFHR: Michael Smith Foundation for Health Research • Peer‐reviewed grants: Grants awarded through government agencies • CT: Clinical Trials • IICT: Investigator‐ Initiated Clinical Trials • RISe: Researcher Information Services (new database) • ORSIL‐ Office of Research Services, Industry Liaison (old database)

TECHNICAL NOTES


C

5.2. Number of invention disclosures Rationale: This indicator measures the extent to which PHC has been able to develop new technologies stemming

from research performed at Providence as compared to the previous fiscal year(s).

Numerator: Number of invention disclosures

Denominator: ‐

Calculation: ‐

Data source: UBC UILO Inteum Database


Target source: ‐


References: ‐

Notes: UILO: University‐ Industry Liaison Office

Acknowledgements This report was assembled by the Administrative Decision Support team. Indicator Leaders, Health Records, Finance, Information Systems, and Client Registration provided a significant amount of support and input into the preparation of this report. All photos were provided by Providence Health Care’s Media Services Centre.

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