tsh scorecard corporate - 2010 11 q3 d
DESCRIPTION
TRANSCRIPT
Page 1
Our 1st Priority (to 30-Jun-11) Indicator
1st Qtr Reported
Current Value
Previous Value Target
Current Status
Risk Rating* Page
Patient satisfaction - Overall Impression:● ED: Would you recommend TSH for Emergency Department services? 49.1 49.7 50 R H 2
● IP: Would you recommend TSH for an In-patient stay? 67.2 61.9 73 Y n/a 2
Percentage of publicly reported patient safety indicators meeting the provincial target (see addendum) 63% 58% 100% Y n/a 4
Number of incident reports completed (medication and non-medication) 743 730 490 G n/a 6
Hospital Standardized Mortality Ratio (HSMR) 74 84 100 G n/a 7
Rate of hand hygiene compliance before initial patient/patient environment contact 85% 92% 90% R 8
Rate of hand hygiene compliance after patient/patient environment contact 89% 96% 90% R 8
Percentage of staff and physicians educated in Mission, Vision and Values defined behaviours Q4Staff and Physician satisfaction:
● Employee Satisfaction survey results (Commitment composite score) 50.9% 37.5% 59% Y n/a 9
● Physician Satisfaction survey results (Commitment composite score) 42.7% 28.8% 43% Y n/a 10
Percentage of defined Model of Care positions transitioned 100% 100% G n/a 11
Performance evaluations● Percentage of leaders with completed performance evaluations Q3 100%
● Percentage of Medical Directors with completed performance evaluations Q3 80% 100% Y n/a 12
● Percentage of non-union staff with completed performance evaluations Q3 100%
● Percentage of unionized staff with completed performance evaluations Q3 50%
Percentage of leaders educated in LEAN methodology Q4HIT indicator #17, Percentage of equipment cost to total expense 5.2% 5.4% 5.9% R M 13
Number of standardized order sets used Q1 2011/12
Percentage of Clinical Service Plan (CSP) recommendations implemented Q4 100%
Percentage of PMO project milestones met 47% 96% 80% R M 14
Percentage of Programs and Departments with performance indicator scorecards and action plans that are posted and updated quarterly on the Intranet 75% 75% 100% Y n/a 15
Total margin 0.30% -0.31% 0% G n/a 16
Percentage of accountability agreement indicators achieved 88% 88% 80% G n/a 17
* Risk rating only completed for indicators that are not meeting the target and have not improved over the prior reporting period
Current Status Legend:Red = Performance indicator has not met the target for the current reporting period, and has not improved over the prior reporting periodYellow = Performance is below the target, however it has improved over the previous reporting periodGreen = Performance indicator has met or exceeded or is not statistically different than the performance target for the current reporting period
Our People: Be the first choice for motivated, talented people who are inspired to deliver and support excellent care in a diverse environment.
Strategic DirectionOur Patients: Create an environment of patient safety that exceeds our patients' highest expectations and delivers care that is patient and family driven.
Service Excellence: To
provide respectful and responsive service to our
patients and each other.
Values: I ntegrity, C ompassion, A ccountability, R espect, E xcellence
Our Programs, Plans and Partners: As a unified organization, lead the development of a coordinated plan for the provision of care for all of Scarborough.
Mission: To provide an outstanding care experience that meets the unique needs of each and every patient.
Our Performance: Create an accountable, high performing organization that delivers measureable results.
Vision: To be recognized as Canada’s leader in providing the best healthcare for a global community.
M = Medium reputational, financial or operational riskH = High reputational, financial or operational risk
Risk Rating LegendL = Low reputational, financial or operational risk
The Scarborough HospitalCorporate Balanced Scorecard
Q3 2010/11
Page Addendum
IndicatorCurrent Value
Previous Value Target
Current Status Risk Rating* Page
Our Patients:
Emergency Department Wait Time for High Acuity Visits - General Campus 19:35 15:12 8:00 R H A1Emergency Department Wait Time for High Acuity Visits - Birchmount Campus 22:51 12:12 8:00 R H A2Emergency Department Wait Time for Low Acuity Visits - General Campus 5:31 4:48 4:00 R H A3Emergency Department Wait Time for Low Acuity Visits - Birchmount Campus 4:57 4:30 4:00 R H A4Percent of CTAS 1&2 meeting 8 hour target 66% 71% 90% R H A5Percent of CTAS 3 meeting 6 hour target 66% 73% 90% R H A6Percent of CTAS 4&5 meeting 4 hour target 79% 84% 90% R H A7Rate of Hospital Acquired C. difficile Associated Diarrhea 0.32 0.22 0.28 R M A8Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia 0.00 0.00 0.02 G n/a A9Rate of Hospital Acquired Vancomycin Resistant Enterococcus (VRE) Bacteraemia 0.00 0.00 0.00 G n/a A10Rate of Central Line Infection (CLI) 1.48 0.61 0.75 R A11Rate of Ventilator Associated Pneumonia (VAP) 0.00 0.76 1.46 G n/a A12Rate of Timely Administration of Prophylactic Antibiotics - Primary Hip & Knee 98.0% 97.6% 96.1% G n/a A13Wait Time - General Surgery 82 67 182 G n/a A14Wait Time - Cancer Surgery 65 54 84 G n/a A15Wait Time - Cataract Surgery 123 223 182 G n/a A16Wait Time - Total Hip Replacement 123 151 182 G n/a A17Wait time - Total Knee Replacement 106 153 182 G n/a A18Wait Time - CT 20 23 28 G n/a A19Wait Time - MRI 99 116 28 Y M A20
* Risk rating only completed for indicators that are not meeting the target and have not improved over the prior reporting period
Status Legend: Risk Rating LegendRed = Performance indicator has not met the target for the current reporting period, and has not improved over the prior reporting period L = Low reputational, financial or operational riskYellow = Performance is below the target, however it has improved over the previous reporting period M = Medium reputational, financial or operational riskGreen = Performance indicator has met or exceeded or is not statistically different than the performance target for the current reporting period H = High reputational, financial or operational risk
Strategic Direction
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Values: I ntegrity, C ompassion, A ccountability, R espect, E xcellence
Vision: To be recognized as Canada s leader in providing the best healthcare for a global community.Mission: To provide an outstanding care experience that meets the unique needs of each and every patient.
Page A1
Performance Measurement Summary
Action PlanInitiative Lead Date Initiated Status
Strategic Direction Our Patients
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Emergency Department Wait Time for High Acuity Visits - General Campus
DefinitionThis indicator reports the 90th Percentile Wait time for all ED Admits with CTAS 1-5 and NonAdmits with CTAS 1-3.
CHART PLACEHOLDER
SignificanceThis indicator is associated with efficiency within the ED and within the hospital, as well as with ED patient satisfaction.
TargetMOHLTC Target - 8:00, lower value is desired.
Risk RatingHigh - There will be reputational impact of dissatisfied patients waiting in Emergency Department and potential financial risk of losing Pay-for-Results funding.
Analysis
Time Frame Q4 2010/11 (Jan)Source MOHLTC Wait Times Website / NACRS
There are challenges related to discharge processes, bed turnover times, and bed availability. As a result of ED PIP, white boards, discharge huddles, patient education and discharge processes have improved on participating units. Spreading the concept to other units is underway. Changing the philosophy to shared accountability for patients is spreading.
GEM D. Driver Oct-09 OngoingED PIP initiated J. Phan Sep-09 Ongoing
Virtual CDU implemented Dr T. Chan Apr-10 OngoingCharge Nurse and Triage RN Education T. Reardon Mar-10 Ongoing
Rounding for Outcomes D. Edman Jun-10 OngoingSchedule to Demand D. Edman Jun-10 Completed
NP LTC B. Bickle Jun-10 OngoingPerformance Huddles Leadership Team Jun-10 Ongoing
Schedule to Demand M. Tang Jan-11 PendingED PIP Kaizen Events S. Gilbert Aug-10 In progress
15:5
4, n
=805
1
15:3
1, n
=793
8
15:3
2, n
=851
2
16:4
7, n
=851
7
15:4
8, n
=888
3
13:1
2, n
=974
7
15:1
2, n
=107
27
19:3
5, n
=351
8
0:00
2:00
4:00
6:00
8:00
10:00
12:00
14:00
16:00
18:00
20:00
22:00
General Campus Target
Page A2
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Emergency Department Wait Time for High Acuity Visits - Birchmount Campus
DefinitionThis indicator reports the 90th Percentile Wait time for all ED Admits with CTAS 1-5 and NonAdmits with CTAS 1-3.
CHART PLACEHOLDER
SignificanceThis indicator is associated with efficiency within the ED and within the hospital, as well as with ED patient satisfaction.
TargetMOHLTC Target - 8:00, lower value is desired.
Risk RatingHigh - There will be reputational impact of dissatisfied patients waiting in Emergency Department and potential financial risk of losing Pay-for-Results funding.
Analysis
Time Frame Q4 2010/11 (Jan)Source MOHLTC Wait Times Website / NACRS
Status
There are challenges related to specialty consultations and Diagnostic Imaging procedures.
Initiative Lead Date Initiated
GEM E. Laine Jun-09 OngoingLaboratory Technologists G. Bajwa Sep-09 Ongoing
Charge Nurse and Triage RN Education L. Vanden Kroonenberg Mar-10 OngoingNP LTC
ED PIP initiated N. Alli, T. Osgood May-10 In progressVirtual CDU implemented Dr T. Chan Apr-10
M. Tang Jun-10 Ongoing
S. Vellani Jun-09 Ongoing
Schedule to Demand M. Tang Jan-11 Pending
Ongoing
Performance Huddles Leadership Team Jun-10 OngoingRounding for Outcomes
17:0
2, n
=638
7
15:3
0, n
=632
5
16:4
5, n
=656
1
16:3
1, n
=667
3
14:0
6, n
=666
8
13:3
6, n
=681
2
12:1
2, n
=716
6
22:5
1, n
=251
9
0:00
2:00
4:00
6:00
8:00
10:00
12:00
14:00
16:00
18:00
20:00
22:00
0:00
2:00
Birchmount Campus Target
Page A3
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Emergency Department Wait Time for Low Acuity Visits - General Campus
DefinitionThis indicator reports the 90th Percentile Wait time for all NonAdmit with CTAS 4-5 visits.
CHART PLACEHOLDER
SignificanceThis indicator is associated with efficiency within the ED and within the hospital, as well as with ED patient satisfaction.
TargetMOHLTC Target - 4:00, lower value is desired.
Risk RatingHigh - There will be reputational impact of dissatisfied patients waiting in Emergency Department and potential financial risk of losing Pay-for-Results funding.
Analysis
Time Frame Q4 2010/11 (Jan)Source MOHLTC Wait Times Website / NACRS
Status
There are challenges related to flow of patient treatment between major and minor cases.
See and Treat Model of Care
Initiative Lead Date Initiated
ED PIP initiated J. Phan, N. Velosos Sep-09
Jun-10
OngoingRPN Role D. Edman Jun-09 Ongoing
Rounding for Outcomes D. Edman Jun-10 OngoingOngoing
ED Staff Mar-10 In progress
Kaizen Events S. Gilbert Aug-10 In progressPerformance Huddles Leadership Team
06:3
7, n
=522
0
05:3
7, n
=547
7
06:0
7, n
=532
5
05:5
4, n
=448
7
05:4
2, n
=477
9
05:1
2, n
=448
1
04:4
8, n
=371
3
05:3
1, n
=124
5
0:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
General Campus Target
Page A4
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Emergency Department Wait Time for Low Acuity Visits - Birchmount Campus
DefinitionThis indicator reports the 90th Percentile Wait time for all NonAdmit with CTAS 4-5 visits.
CHART PLACEHOLDER
SignificanceThis indicator is associated with efficiency within the ED and within the hospital, as well as with ED patient satisfaction.
TargetMOHLTC Target - 4:00, lower value is desired.
Risk RatingHigh - There will be reputational impact of dissatisfied patients waiting in Emergency Department and potential financial risk of losing Pay-for-Results funding.
Analysis
Time Frame Q4 2010/11 (Jan)Source MOHLTC Wait Times Website / NACRS
Status
There are challenges related to flow of patient treatment between major and minor cases.
Initiative Lead Date Initiated
ED PIP initiated N. Alli, T. Osgood May-10 In progressRPN Role D. Edman Jun-09 Ongoing
Performance Huddles Leadership Team Jun-10 OngoingRounding for Outcomes D. Edman Jun-10 Ongoing
See and Treat Model of Care ED Staff Aug-10 In progress
06:3
7, n
=390
5
05:3
7, n
=389
4
06:0
7, n
=381
1
05:5
4, n
=327
1
05:1
8, n
=398
0
05:0
0, n
=395
0
04:3
0, n
=397
3
04:5
7, n
=118
8
0:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
Birchmount Target
Page A5
Performance Measurement Summary
Action Plan
Performance Huddles Leadership Team Jun-10 Ongoing
ED PIP Kaizen Events S. Gilbert Aug-10 In progressJun-10 OngoingNP LTC B. Bickle
Schedule to Demand D. Edman Jun-10 CompletedRounding for Outcomes D. Edman Jun-10 Ongoing
Virtual CDU implemented Dr T. Chan Apr-10 OngoingCharge Nurse and Triage RN Education T. Reardon Mar-10 OngoingGEM D. Driver Oct-09 OngoingED PIP initiated J. Phan Sep-09 OngoingInitiative Lead Date Initiated Status
Source MOHLTC Wait Times Website / NACRS
DefinitionThis indicator reports the percentage of ED patients with CTAS 1 and 2 who completed their visit (Registration to Leaving ED) within 8 hours.
CHART PLACEHOLDER
SignificanceTo ensure adequate patient access and flow within ED and hospital.
TargetMOHLTC Target - 90%, higher value is desired.
Risk RatingHigh - There will be reputational impact of dissatisfied patients waiting in Emergency Department and potential financial risk of losing Pay-for-Results funding.
AnalysisThere are challenges related to specialty consultations and Diagnostic Imaging procedures. A Diagnostic Imaging Kaizen event is taking place to improve Diagnostic Imaging callbacks wait times.
Strategic Direction Our PatientsTime Frame Q4 2010/11 (Jan)
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Percent of CTAS 1&2 meeting 8 hour target
67%
, n=1
912
68%
, n=1
854
66%
, n=1
773
64%
, n=1
795
69%
, n=2
045
70%
, n=2
332
71%
, n=2
787
67%
, n=8
55
65%
, n=1
216
68%
, n=1
203
69%
, n=1
228
66%
, n=1
181
69%
, n=1
203
73%
, n=1
401
73%
, n=1
413
65%
, n=4
63
66%
, n=3
128
68%
, n=3
057
67%
, n=3
001
65%
, n=2
976
69%
, n=3
248
71%
, n=3
733
71%
, n=4
200
66%
, n=1
318
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
General Birchmount TSH Target
Page A6
Performance Measurement Summary
Action Plan
Performance Huddles Leadership Team Jun-10 Ongoing
ED PIP Kaizen Events S. Gilbert Aug-10 In progressJun-10 OngoingNP LTC B. Bickle
Schedule to Demand D. Edman Jun-10 CompletedRounding for Outcomes D. Edman Jun-10 Ongoing
Virtual CDU implemented Dr T. Chan Apr-10 OngoingCharge Nurse and Triage RN Education T. Reardon Mar-10 OngoingGEM D. Driver Oct-09 OngoingED PIP initiated J. Phan Sep-09 OngoingInitiative Lead Date Initiated Status
Source MOHLTC Wait Times Website / NACRS
DefinitionThis indicator reports the percentage of ED patients with CTAS 3 who completed their visit (Registration to Leaving ED) within 6 hours.
CHART PLACEHOLDER
SignificanceTo ensure adequate patient access and flow within ED and hospital.
TargetMOHLTC Target - 90%, higher value is desired.
Risk RatingHigh - There will be reputational impact of dissatisfied patients waiting in Emergency Department and potential financial risk of losing Pay-for-Results funding.
AnalysisThere are challenges related to specialty consultations and Diagnostic Imaging procedures. A Diagnostic Imaging Kaizen event is taking place to improve Diagnostic Imaging callbacks wait times.
Strategic Direction Our PatientsTime Frame Q4 2010/11 (Jan)
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Percent of CTAS 3 meeting 6 hour target
51%
, n=2
604
60%
, n=3
050
60%
, n=3
399
60%
, n=3
381
65%
, n=3
784
72%
, n=4
553
73%
, n=4
877
67%
, n=1
486
58%
, n=2
563
63%
, n=2
771
58%
, n=2
721
61%
, n=2
837
65%
, n=3
130
67%
, n=3
203
72%
, n=3
698
66%
, n=1
167
55%
, n=5
167
61%
, n=5
821
59%
, n=6
120
60%
, n=6
218
65%
, n=6
914
70%
, n=7
756
73%
, n=8
575
66%
, n=2
653
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
General Birchmount TSH Target
Page A7
Performance Measurement Summary
Action Plan
Kaizen Events S. Gilbert Aug-10 In progressPerformance Huddles Leadership Team Jun-10 OngoingRounding for Outcomes D. Edman Jun-10 OngoingSee and Treat Model of Care ED Staff Mar-10 In progress ED-PIP initiated J. Phan, N. Velosos Sep-09 OngoingRPN Role D. Edman Jun-09 OngoingInitiative Lead Date Initiated Status
Source MOHLTC Wait Times Website / NACRS
DefinitionThis indicator reports the percentage of ED patients with CTAS 4 and 5 who completed their visit (Registration to Leaving ED) within 4 hours.
CHART PLACEHOLDER
SignificanceTo ensure adequate patient access and flow within ED and hospital.
TargetMOHLTC Target - 90%, higher value is desired.
Risk RatingHigh - There will be reputational impact of dissatisfied patients waiting in Emergency Department and potential financial risk of losing Pay-for-Results funding.
AnalysisThere are challenges related to flow of patient treatment between major and minor cases.
Strategic Direction Our PatientsTime Frame Q4 2010/11 (Jan)
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Percent of CTAS 4&5 meeting 4 hour target
72%
, n=3
864
76%
, n=4
280
73%
, n=3
974
75%
, n=3
457
73%
, n=3
534
79%
, n=3
600
82%
, n=3
101
78%
, n=9
88
66%
, n=2
644
74%
, n=2
978
68%
, n=2
634
71%
, n=2
406
76%
, n=3
093
81%
, n=3
253
85%
, n=3
438
80%
, n=9
77
69%
, n=6
508
75%
, n=7
258
71%
, n=6
608
73%
, n=5
863
74%
, n=6
627
80%
, n=6
853
84%
, n=6
539
79%
, n=1
965
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11 (Jan)
General Birchmount TSH Target
Page A8
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Rate of Hospital Acquired C. difficile Associated Diarrhea
There have been a few months of increased cases of C. difficile at the General Campus since February 2010. Rates have begun to decline with increased monitoring and vigilance of infection control practices in the inpatient areas. The Birchmount Campus remains below the Ontario Average.
Definition Overall Rate of hospital acquired C. difficile associated diarrhea. Rate is based on total number of inpatients/patients with confirmed infection per 1000 patient-days.
CHART PLACEHOLDER
SignificanceTo track hospital acquired C. difficile rates in order to identify and implement infection control measures to prevent nosocomial spread of C. difficile. While C. difficile does not usually present a big problem for reasonably healthy adults, it can be quite serious for those who are frail or have other health challenges.
TargetOntario Average - 0.28, lower value is desired.
Risk RatingMedium- Controlling the rate of infection is very important to TSH. The increase in the rate of infection may cause some financial and reputational risk to the organization.
Analysis
Feb-11
Time Frame May 2011Source Surveillance and Case Finding
StatusIncreased vigilance to IPAC guidelines around C. difficile management for both campuses and enviromental audits of units
E. Lipnicki Jan-11 Ongoing
In progress
"Vernacare" system for both campuses emphasizing safe disposable of wastes on units has been implemented E. Lipnicki Jun-10 Completed
Initiative Lead Date Initiated
Proposal being made for an antimicrobial stewardship program to help decrease the use of antibiotics associated with the development of C. difficile
IPAC/Pharmacy
0.11
, n=1
0.35
, n=3
0.12
, n=1
0.00
, n=0
0.36
, n=3
0.23
, n=2
0.24
, n=2
0.46
, n=4
0.37
, n=3
0.13
, n=1
0.13
, n=1 0.
26, n
=2
0.58
, n=5
0.58
, n=5
0.45
, n=4
0.53
, n=5
0.25
, n=2
0.45
, n=4
1.09
, n=9
0.48
, n=4
0.46
, n=3
0.48
, n=3
0.00
, n=0
0.00
, n=0
0.51
, n=3
0.49
, n=3
0.16
, n=1
0.49
, n=3
0.00
, n=0
0.34
, n=2
0.00
, n=0
0.00
, n=0
0.33
, n=2
0.00
, n=0
0.00
, n=0
0.15
, n=1
0.17
, n=1
0.15
, n=1
0.34
, n=2 0.
47, n
=3
0.26
, n=4 0.
40, n
=6
0.07
, n=1
0.00
, n=0
0.43
, n=6
0.34
, n=5
0.20
, n=3
0.47
, n=7
0.22
, n=3
0.22
, n=3
0.07
, n=1
0.15
, n=2
0.47
, n=7
0.35
, n=5
0.26
, n=4 0.
38, n
=6
0.22
, n=3 0.32
, n=5
0.78
, n=1
1
0.47
, n=7
-
0.20
0.40
0.60
0.80
1.00
1.20
Oct
09
Nov
09
Dec
09
Jan
10
Feb
10
Mar
10
Apr
10
May
10
Jun
10
Jul 1
0
Aug
10
Sep
10
Oct
10
Nov
10
Dec
10
Jan
11
Feb
11
Mar
11
Apr
11
May
11
General Campus Birchmount Campus
TSH Ontario Average per 1,000 patient-days
TSH Rolling 12-month Average
Page A9
Performance Measurement Summary
Action Plan
SignificanceHigher MRSA colonization rates will lead to higher rates of blood stream infections with MRSA. Tracking hospital acquired MRSA Bacteraemia rates helps to identify the clinical significance of MRSA colonization. This will help identify a need for further strategies to prevent nosocomial spread of MRSA.
Analysis
TargetOntario Average - 0.02, lower value is desired.
Strategic Direction Our Patients
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia
Continue with MRSA surveillance protocols E. Lipnicki Jul-10 Ongoing
Time Frame Q4 2010/11 Source Surveillance and Case Finding
Definition Overall Rate of hospital acquired Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia. Rate is based on total number of inpatients/patients with confirmed infection per 1000 patient-days.
CHART PLACEHOLDERRisk Ratingn/a
Begin universal screening for MRSA colonization on admission IPAC Dec-10 In progress
Both General Campus and Birchmount Campus remains below the Ontario Average.
Initiative Lead Date Initiated Status
0.11
, n=1
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.06
, n=1
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
0.01
0.02
0.03
0.04
0.05
0.06
General Campus Birchmount Campus
TSH Ontario Average per 1,000 patient-days
TSH Rolling 12-month Average
Page A10
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Rate of Hospital Acquired Vancomycin Resistant Enterococcus (VRE) Bacteraemia
There have been no reportable cases of VRE bacteraemia despite increased numbers of VRE colonized patients since April 2010.
Definition Overall Rate of hospital acquired Vancomycin Resistant Enterococcus (VRE) bacteraemia. Rate is based on total number of inpatients/patients with confirmed infection per 1000 patient-days.
CHART PLACEHOLDER
SignificanceTo track hospital acquired VRE bacteraemia rates in order to identify and implement necessary prevention plans to reduce the risk of infection from spreading.
TargetOntario Average - 0.00, lower value is desired.
Risk Ratingn/a
Analysis
Dec-10
Time Frame Q4 2010/11 Source Surveillance and Case Finding
StatusVRE colonization outbreak over July 2010. Continue with IPAC protocols and ICRT recommendations for surveillance and outbreak management policies
E. Lipnicki Apr-10 Completed July 2010
In progress
ICRT invited for third party review July 20, 2010- waiting for final recommendations E. Lipnicki Jul-10 Completed
Initiative Lead Date Initiated
Universal screening to be implemented to identify patients colonized with VRE on admission and thus reduce nosocomial spread IPAC
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.000
0.002
0.004
0.006
0.008
0.010
0.012
General Campus Birchmount Campus
TSH Ontario Average per 1,000 patient-days
TSH Rolling 12-month Average
Page A11
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Rate of Central Line Infection (CLI)
There has been a marked improvement to the number of CLI cases at TSH in January 2011. CLI strategies to standardize processes across the campuses is showing improvements in the rates.
Definition Overall rate of hospital acquired Central Line Infection. Rate is based on total number of CLI incidents diagnosed after two days of Critical Care admission per 1000 patient days.
CHART PLACEHOLDER
SignificanceTo track hospital acquired CLI rates in order to identify and implement necessary prevention plans to reduce the risk of infection from spreading.
Target Ontario Average - 0.75, lower value is desired.
Risk Ratingn/a
Analysis
Apr-10
Time Frame Q4 2010/11Source Surveillance and Case Finding
Status
Interdisciplinary team meetings to standardize protocols at the Birchmount Campus including physician and nursing education
H. Clasky, D. Rose, S. Cesta, R. Lovinsky
Jan-10 Ongoing
OngoingChlohexidine dressings to help prevent CLIs
H. Clasky, D. Rose, S. Cesta, R. Lovinsky
Apr-10 Completed
Initiative Lead Date Initiated
Ongoing monitoring of insertion and maintenance BundleH. Clasky, D. Rose, S. Cesta, R. Lovinsky
1.14
, n=1
0.00
, n=0
4.98
, n=5
6.32
, n=6
0.00
, n=0
2.21
, n=2
0.00
, n=0
2.06
, n=3
0.00
, n=0
0.00
, n=0
1.87
, n=1
0.00
, n=0
2.36
, n=1
2.54
, n=1
1.88
, n=1
0.00
, n=00.
75, n
=1
0.00
, n=0
3.90
, n=6 4.58
, n=6
0.69
, n=1
2.31
, n=3
0.61
, n=1 1.
48, n
=3
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11
General Campus Birchmount Campus
TSH Ontario Average per 1,000 patient-days
TSH Rolling 12-month Average
Page A12
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Rate of Ventilator Associated Pneumonia (VAP)
Definition Overall Rate of hospital acquired Ventilator Associated Pneumonia. Rate is based on total number of VAP incidents diagnosed after two days of Critical Care admission per 1000 patient days.
CHART PLACEHOLDER
SignificanceTo track hospital acquired VAP rates in order to identify and implement necessary prevention plans to reduce the risk of development of pneumonia in the ICU patient population.
Target Ontario Average - 1.46, lower value is desired.
Risk Ratingn/a
Analysis
Time Frame Q4 2010/11Source Surveillance and Case Finding
Status
Continue monitoring compliance bundles (maintenance and insertion) J.MacIsasc Jan-11 In progress
Interdisciplinary meeting with Birchmount Critical Care team to ensure compliance with safer healthcare bundle. Development of unit based scorecard to track progress. Ensure standardization between campuses.
Dr. Clasky, C. Shelton, S. Cesta, R. Lovinsky
Jan-11 In progress
There were no VAP cases identified at TSH in January 2011.
Initiative Lead Date Initiated
1.76
, n=1
0.00
, n=0
1.31
, n=1
2.47
, n=2
0.00
, n=0
1.40
, n=1
1.14
, n=1
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.00
, n=0
4.56
, n=2
0.00
, n=0
0.00
, n=0
0.00
, n=0
0.97
, n=1
0.00
, n=0
0.78
, n=1
1.58
, n=2
1.63
, n=2
0.90
, n=1
0.76
, n=1
0.00
, n=0
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11
General Campus Birchmount CampusTSH Ontario Average per 1,000 patient-daysTSH Rolling 12-month Average
Page A13
Performance Measurement Summary
Action PlanStatus
Ensure compliance through audits
All surgeon's offices have pre-printed orders. Work continues on ensuring a good process for improvement on this indicator. The drop at Birchmount Campus was due to one case where the patient received the antibiotic outside the recommended time. This was because pre-op orders did not reference that Clindamychi must be given 60 minutes pre-op. This has now been rectified.
Initiative Lead Date Initiated
Implement standard order sets to improve compliance Nurse Educators Sep-09 CompletedPCMs Apr-09 In progress
Source Medical Systems Management (OR System)
DefinitionSurgical site infections occur when harmful germs enter a patient’s body through the surgical site (any cut the surgeon makes in the skin to perform the operation). Ways to prevent surgical site infections is by giving patients antibiotics 0 to 60 minutes or 0 to 120 minutes (vancomycin antibiotic) before they undergo surgery.
CHART PLACEHOLDER
Significance Conducting post-surgical infection surveillance and measuring the application of prophylactic antibiotics can be useful to enhance safety and quality of care, and to prevent complications thereby decreasing morbidity and mortality rates.
Risk Ratingn/a
Analysis
Indicator Rate of Timely Administration of Prophylactic Antibiotics - Primary Hip & KneeStrategic Direction Our Patients
TargetOntario Average - 96.1%, higher value is desired.
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Time Frame Q3 2010/11
95.7
%, n
=178
99.2
%, n
=243
98.7
%, n
=231
99.1
%, n
=216
99.4
%, n
=155
97.3
%, n
=215
97.2
%, n
=205
95.9
%, n
=71
98.7
%, n
=74
100.
0%, n
=60
95.9
%, n
=70
98.2
%, n
=56
98.5
%, n
=64
100.
0%, n
=85
95.8
%, n
=249
99.1
%, n
=317
99.0
%, n
=291
98.3
%, n
=286
99.1
%, n
=211
97.6
%, n
=279
98.0
%, n
=290
0%
20%
40%
60%
80%
100%
120%
Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11
General Campus Birchmount Campus TSH Ontario Avg.Target
Page A14
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Wait Time - General Surgery
DefinitionWait time is defined as the 90th percentile number of days between the date of decision to treat and the time the surgical procedure is performed.
CHART PLACEHOLDER
SignificanceA measure of access and efficiency for patients requiring these procedures.
TargetMOHLTC Target - 182, lower value is desired.
Risk Ratingn/a
Analysis
Time Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPort
Status
General Surgery is performing well against Ontario average and provincial target. Patients are seen in a timely manner.
Initiative Lead Date Initiated
Continue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Dec-10 OngoingHire of two new General Surgeons TSH Senior team Dec-09 Completed
Allocate OR time to services with wait time cases N. Rahim Dec-10 Ongoing
68, n
=279
84, n
=279
61, n
=387
67, n
=314
68, n
=475
75, n
=397
75, n
=415
87, n
=499
88, n
=524
83, n
=419
67, n
=457
82, n
=356
-
20
40
60
80
100
120
140
160
180
200
TSH Ontario Target
Page A15
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Wait Time - Cancer Surgery
Cancer Surgery is performing well against Ontario average and provincial target. Patients are seen in a timely manner.
DefinitionWait time is defined as the 90th percentile number of days between the date of decision to treat and the time the surgical procedure is performed.
CHART PLACEHOLDER
SignificanceA measure of access and efficiency for patients requiring these procedures.
TargetMOHLTC Target - 84, lower value is desired.
Risk Ratingn/a
Analysis
Dec-10
Time Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPort
Status
OngoingContinue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Dec-10 OngoingInitiative Lead Date Initiated
Allocate OR time to services with wait time cases N. Rahim
43, n
=100
46, n
=159
60, n
=217
53, n
=234
50, n
=169
59, n
=192
74, n
=223
49, n
=221
57, n
=191
54, n
=173 65
, n=2
67
-
10
20
30
40
50
60
70
80
90
TSH Ontario Target
Page A16
Performance Measurement Summary
Action Plan
SignificanceA measure of access and efficiency for patients requiring these procedures.
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Wait Time - Cataract SurgeryStrategic Direction Our Patients
TargetMOHLTC Target - 182, lower value is desired.
Time Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPort
DefinitionWait time is defined as the 90th percentile number of days between the date of decision to treat and the time the surgical procedure is performed.
CHART PLACEHOLDERRisk Ratingn/a
Analysis
Status
The wait time for cataract surgery has decreased between January to February 2011 below the provincial target. Previous wait times was due to the lack of funding from CE LHIN for 2010/11. Funded volumes have decreased for TSH by 315 cases compared to 2009/10. In Q4 the CE LHIN allocated additional 400 cataracts to assist TSH to bring down the 90th percentile for cataracts. The additional cataract volumes have already impacted January's wait time. Q4 wait times will also be lower than Q3 due to data clean-up efforts undertaken.
Initiative Lead Date Initiated
Allocate OR time to services with wait time cases N. Rahim Dec-10 OngoingContinue to monitor the performance of surgeons, wait time and OR blocks utilization N. Rahim Dec-10 Ongoing
Ensure data quality check and re-education of Ophthalmology office staff to understand how to use of Decision Affecting Readiness to Treat (DARTs) Option on patients Wait Time records
N. Rahim Jan-11 In progressAllocate OR time to the Ophthalmology surgeons with wait times exceeding the WTIS target of 182 days N. Rahim Oct-10 In progress
157,
n=1
409
138,
n=1
423
145,
n=1
418
145,
n=1
453
150,
n=1
613
149,
n=1
325
155,
n=1
434
165,
n=1
134
197,
n=1
438
212,
n=1
368
223,
n=1
331
123,
n=1
242
-
50
100
150
200
250
TSH Ontario Target
Page A17
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Wait Time - Total Hip Replacement
Total Hip Replacement Surgery is performing well against Ontario average and provincial target. Patients are seen in a timely manner.
DefinitionWait time is defined as the 90th percentile number of days between the date of decision to treat and the time the surgical procedure is performed.
CHART PLACEHOLDER
SignificanceA measure of access and efficiency for patients requiring these procedures.
TargetMOHLTC Target - 182, lower value is desired.
Risk Ratingn/a
Analysis
Dec-10
Time Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPort
Status
OngoingContinue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Oct-09 OngoingInitiative Lead Date Initiated
Allocate OR time to services with wait time cases N. Rahim
171,
n=5
2
117,
n=4
3
145,
n=6
1
130,
n=5
0
146,
n=7
7
131,
n=6
4
108,
n=8
7
114,
n=6
2
116,
n=7
4
124,
n=5
7
151,
n=6
3
123,
n=4
3
-
50
100
150
200
250
TSH Ontario Target
Page A18
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Wait Time - Total Knee Replacement
Total Knee Replacement Surgery is performing well against Ontario average and provincial target. Patients are seen in a timely manner.
DefinitionWait time is defined as the 90th percentile number of days between the date of decision to treat and the time the surgical procedure is performed.
CHART PLACEHOLDER
SignificanceA measure of access and efficiency for patients requiring these procedures.
TargetMOHLTC Target - 182, lower value is desired.
Risk Ratingn/a
Analysis
Dec-10
Time Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPort
Status
OngoingContinue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Oct-09 OngoingInitiative Lead Date Initiated
Allocate OR time to services with wait time cases N. Rahim
192,
n=2
02
159,
n=1
81
145,
n=2
42
124,
n=2
21
117,
n=2
23
113,
n=2
02
114,
n=2
41
124,
n=2
36
124,
n=2
22
130,
n=1
59
153,
n=2
22
106,
n=1
44
-
50
100
150
200
250
TSH Ontario Target
Page A19
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Wait Time - CT
DefinitionWait time is defined as the 90th percentile number of days wait for CT diagnostic scan.
CHART PLACEHOLDER
SignificanceTrack the wait time indicators to ensure that we are meeting our MOHLTC commitments and meeting the needs of our patients.
TargetMOHLTC Target - 28, lower value is desired.
Risk Ratingn/a
Analysis
Time Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPort
Status
Reduction noted based on changes to scheduling patterns and improvement in data capture as a result of retraining of staff. There are longer waits for priority 3, as many requests involve the use of contrast media and these appointments are limited.
Review existing contrast media delivery policy and explore options for extending contrast appointments T. Jackson Sep-10 PendingApplication for second CT at General Campus in Satellite location; will decrease all Wait Times
Initiative Lead Date Initiated
WTIS data error resolution done on a monthly basis - indicates data entry errors - follow up with staff Charge clerksT. Jackson Sep-10 Pending
In progressWait time data entry training for booking clerks V. Winters Nov-09 Completed
Nov-09
34, n
=509
1
41, n
=475
7
32, n
=503
0
38, n
=510
5
38, n
=507
7
39, n
=517
6
36, n
=538
7
29, n
=516
9
21, n
=551
0
23, n
=517
7
23, n
=560
5
20, n
=396
8
-
5
10
15
20
25
30
35
40
45
50
TSH Ontario Target
Page A20
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough HospitalCorporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Wait Time - MRI
DefinitionWait time is defined as the 90th percentile number of days wait for MRI diagnostic scan.
CHART PLACEHOLDER
SignificanceTrack the wait time indicators to ensure that we are meeting our MOHLTC commitments and meeting the needs of our patients.
TargetMOHLTC Target - 28, lower value is desired.
Risk RatingMedium - delays can affect patient care. P4 are the lowest priority. Long waits can negatively impact reputation.
Analysis
Time Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPort
Status
MOHLTC target for priority 4 cases is 28 days and the CELHIN has a target of 76.5 days. Currently exceeding both. Demand for services continues to outstrip available resources. Current MRI Process Improvement Project (PIP) process is reviewing scheduling process for efficiencies. TSH receieved funding from CELHIN in Q4 for 360 additional MRI hours in hopes of decreasing wait times.
Initiative Lead Date Initiated
WTIS data error resolution done on a monthly basis - indicates data entry errors - follow up with staff Charge clerks Nov-09 In progressWait time data entry training for booking clerks V. Winters Nov-09 Completed
Second MRI application sent to CELHIN, LHIN approval moved to MOHLTC T. Jackson Jul-10 In progressOperating hours extended to 24hrs during weekdays for Q4 2010/11 S. Porter Jan-11 In progress
MRI PIP- LEAN process for identifying improvements in MRI throughput S. Porter Jun-10 In progress
61, n
=184
4
64, n
=163
5
79, n
=174
4 101,
n=1
718
99, n
=184
4
103,
n=1
895
118,
n=2
240
133,
n=2
121
109,
n=2
028
107,
n=2
085
116,
n=2
132
99, n
=195
4
-
20
40
60
80
100
120
140
TSH Ontario Target
Page 2
Performance Measurement Summary
Action Plan
QCIPA Reviews• QCIPA case reviews take place whenever an incident, near miss or adverse event occurs• Recommendations are shared with staff
ED Leadership Team Ongoing
Strategic Direction
Source
StatusDate InitiatedLeadInitiative
TSH Emergency Department satisfaction scores is below the target. TSH Inpatient satisfaction scores continue to be below other Greater Toronto Area hospitals. TSH has made positive changes such as Code of Conduct, and faster response time to patient complaint by Patient Relations department.
CHART PLACEHOLDER
TargetTSH target is 50 for ED and 73 for IP, higher value is desired. The target is based on GTA average.
The Scarborough HospitalCorporate Balanced Scorecard
Indicator
Sep-10
SignificanceThis indicator is a measure of patient's overall impression of the quality of care received.
Time Frame
Analysis
Sep-10 Ongoing
Patient satisfaction - Overall Impression (Emergency Department and In-patients)Our PatientsQ3 2010/11NRC Picker
Risk RatingHigh- Reputational, financial or operational risk.
DefinitionResponse to Overall Impression questions in NRC Picker survey administered to a sample of discharged Emergency Department patients and In-patients:- Emergency Department (ED): Would you recommend TSH for Emergency Department services?- Inpatients: Would you recommend TSH for an In-patient stay?
Team Charter, the ED Team Charter defines the purpose of the team, how we all work together and what the expected outcomes will be:• Utilized to lay the foundation of expected team behaviours• Utilized to guide staff in their performance and interactions with patients
Nursing Leadership Team and ED staff
Sep-10 Ongoing
Hiring the right people for the team. The ED will recruit and retain professionals with the right level of knowledge, technical expertise and interpersonal skill.• Select new staff who will make a positive difference to our patients• Select staff who support our mission, vision and values
D. Edman and T. Reardon
36.4
n=1
51
41.5
n=1
35
46.8
n=1
54
48.3
n=1
43
44.3
n=2
12
49.7
n=1
93
49.1
n=1
16
60.4
n=3
59
62.6
n=3
42
59.3
n=3
27
60.9
n=3
22
59.4
n=3
30
61.9
n=3
18
67.2
n=2
71
0
20
40
60
80
100
Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11
ED Score IP Score Target - GTA ED Avg Target - GTA IP Avg
Page 3
D. Edman and N. Alli
D. Edman and T. ReardonPatient friendly waiting roomGeneral Campus:• ED Activity board in place to inform patients in the waiting room about potential wait time• Wayfinding steps to triage, registration and wait room in place to ensure patients queue appropriatelyBirchmount Campus• Re-design waiting room, triage and registration in process• ED activity board in process
Fast track RAZ patientsGeneral Campus:• Elite RAZ staff• Number system to ensure patients are aware of who is next in line• Pull to RAZ waiting roomBirchmount Campus:• Elite RAZ staff• Pull to RAZ waiting room
Completed for Birchmount Campus
Sep-10
Completed for General CampusSep-10
Staff Education, all staff are giving an opportunity to enhance or increase their knowledge and skill:• Charge Nurse workshops• Triage Nurse workshops• Monthly inservicing on selected topics• Customer service education
S. Gilbert and L. Vanden Kroonenberg
Sep-10 Ongoing
Page 4
Performance Measurement Summary
Action PlanInitiative Lead Date Initiated Status
In progress
CompletedIPAC Sep-09 Ongoing
OngoingDr. I. Daves, B. Westcott, IPAC Sep-09
Interdisciplinary meeting with Birchmount critical care team to ensure compliance with safer healthcare bundle. Development of unit based scorecard to track progress. Ensure standardization between campuses
Dr. Clasky, C. Shelton, S. Cesta, R. Lovinsky
Implement standard order sets to improve compliance Nurse Educators Sep-09
An additional 300 hours of wait time funding accepted from CE LHIN reallocation. Implementation of expanded hours of operation to commence Sep-09
Continue to monitor CLI and VAP bundle compliance in Intensive Care Unit
Jan-10
Our Patients
• TSH patients continue to receive timely access to care. TSH wait time for general surgery, hip/knee, CT is below the provincial average.• The wait time for MRI is above the Ontario average, however, the wait time has increased to 116 in Q3 2010/11.• The wait time for cataract surgery has increased in Q3 2010/11 above the provincial target. There is a lack of funding from CE LHIN for 2010/11. Funded volumes have decreased for TSH by 315 cases compared to 2009/10. Wait time for cataracts will continue to increase unless additional funding is received.
SourceQ3 2010/11
Strategic Direction
CHART PLACEHOLDER
SignificanceProvides information on patient safety issues where the goal is to enhance patient safety in the hospital by reducing the risk factors. Monitoring these indicators in the hospital is a priority and is key to keeping patients safe.
TargetTSH Target - 100%, higher value is desired.
Analysis
Early cluster identification and interventions including unit terminal cleaning, use of vernacare system, re-enforcement/education on hand hygiene, cleaning of equipments between patients and prudent use of antibiotics
Time Frame
T. Jackson Sep-09 - Mar-10
Risk Ratingn/a
• There continues to be improvement in our high and low acuity scores at both the General and Birchmount campus compared to a year ago.• There have been an increase in cases of C. Diff at the General campus since Dec-10. Rates have begun to decline with increased monitoring and vigilence of infection control practices in the inpatient areas. The Birchmount campus remains below the Ontario average.• There has been a decrease in the number of CLI cases at the Birchmount campus. Overall, TSH remains below the Ontario average. Standardization of CLI strategies across the campuses will assist in decreasing CLI cases across TSH.• There has been some decrease in VAP cases identified at the General campus and Birchmount campus in the last quarter. Both campuses are now below the Ontario average.• SSI - Antibiotics Timing - Hip/Knee: Work continues on ensuring a good process for improvement on this indicator.
DefinitionPercentage of 19 publicly reported patient safety indicators that meet the provincial targets.
Meditech, NACRS, IPAC, MOHLTC Wait Times Public Website
Completed
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Percentage of publicly reported patient safety indicators meeting the provincial target (see addendum)
53%
, n=1
0
63%
, n=1
2
63%
, n=1
2
58%
, n=1
1
63%
, n=1
2
0%
20%
40%
60%
80%
100%
120%
Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11
% patient safety indicators meeting provincial targets Target
Page 5
Ongoing
E. Lipnicki
Feb-10 CompletedT. Jackson
L. Crawford, Dr. T. Chan Mar-10Mar-10
In progressJul-10
Ongoing
IPAC Feb-10
Feb-10 Ongoing
In progress
In progress
E. Lipnicki
Collaborate with IPAC, Critical Care, Diagnostic Imaging, IV resource and Physician team on type of line to be inserted, compliance with insertion and maintenance bundles. Focus on hand hygiene improvement, reinforce importance of aseptic line access, timely removal of central lines, educate Physicians on line removal, empower nurses to prompt line discontinuation, improve line documentation
B. Westcott, Dr. H. Clasky, Dr. R. Lovinsky, IPAC
Feb-11ED wait times may not be met due to influenza surge during Q3. Cataract surgery wait times down to below target after significant clean up of wait time data in surgeons' offices completed by TSH staff. Continue with additional cleaning of C-diff affected units and auditing of infection control practices on these units. Plans in the works for additional MRI scanner installation at Birchmount summer 2011. This will help reduce MRI wait time
Ongoing
Continue with notification to pharmacy regarding patient’s with diarrhea, early use additional precautions on symptomatic patients until C. Diff is ruled out and standardization of cleaning protocols and products for both campuses
Continue to ensure compliance with SSI - Antibiotics Timing (Hip/Knee). Overall compliance rate is currently 99%
Re institution of the Antibiotic Stewardship Committee to ensure prudent use of antibiotics. Development of a corporate policy for cleaning and disinfecting shared equipments and separation of clean and soiled utility room. Plan for increase vernacare waste macerators
Ongoing
Sep-10 In progress
CLI Rates beginning to drop with subsequent months for the General campus. Continue to monitor progress and collaborative work as outlined below
Continue with MRSA surveillance protocols E. Lipnicki
T. Jackson
RAU
ED Process Improvement Project (PIP) has re-designed the Rapid Assessment Zone (RAZ) for a team approach to see and treat
In progress
In progressOngoing
Jun-10Jul-10
Fall 2010
L. Crawford, A. MacKinnon, N. Veloso
T. Jackson
ED PIP commenced Apr-10 at the Birchmount campus. Value Stream Mapping (VSM) completed. Entering solution design stage with launch on May 26, 2010
L. Crawford,A. MacKinnon, N. Alli
Second MRI application sent to CE LHIN, LHIN approval moved to MOHLTC
Clinical Decision Unit (CDU)L. Crawford, Dr. T. ChanVirtual CDU
IPAC, Dr. R. Lovinsky
Review of "vernacare" system for both campuses emphasizing safe disposal of waste. 4 new vernacare units approved for Birchmount campus in 2010 capital plan
In progress
B. Westcott, Dr. H. Clasky, Dr. R. Lovinsky, IPAC
In progress
Ready for implementation
L. Crawford, A. MacKinnon, Dr. T. Chan
L. Crawford, A. MacKinnon, D. Edman, Dr. T. Chan
May-10 In progress
E. Lipnicki Jun-10
Ongoing
N. Rahim
N. Rahim
N. Rahim
IPAC
May-10Continue to work with the Antibiotic Stewardship Committee to ensure prudent use of antibiotics to lower and maintain rates below the provincial average
Feb-10
Investigate feasibility of extending contrast cases to off-hours: Not supported at this time
In progress
Feb-10
L. Crawford, A. MacKinnon, J. Phan
VRE colonization outbreak over Jul-10. Continue with IPAC protocols and ICRT recommendations for surveillance and outbreak management policies
Feb-10
OngoingWith the addition of 3 General surgeons, access to care should further improve. Continue to monitor wait times and ensure TSH is meeting funded volumesContinue to deliver cataract surgery to funded volumes only. Funding for an additional 123 cases has been received. This volume has already been delivered. Additional finding of 375 cases requested from the CE LHIN
Pursue 2nd CT scanner to increase capacity: Not approved to commence procurement. Linked to achievement of agreed upon nuclear cardiology referral volumes, which have not yet been met
Feb-10
Jan-10
Increased vigilence to IPAC guidelines around C. Diff management for both campuses
Ongoing
To be integrated into base – Sep-10
Apr-10 Completed
Mar-10
ED PIP
E. Lipnicki
Staffing demand for nursing and physicians. Master schedule for nursing staff to be implemented June 21, 2010
MRI PIP - LEAN process for identifying improvements in MRI throughput S. Porter
Pay for Performance (P4R) funding received for year III: Electronic Bed Board; Clinical Facilitator; Laboratory Technologists; See and Treat; Staff to Demand; Rapid Admissions Unit (RAU); LEAN; ED PIP extension
L. Crawford, A. MacKinnon, Dr. T. Chan
ICRT invited for third party review July 20, 2010 - waiting for final recommendations
Feb-10
Completed
Completed
May-10 – General Dec-10 – Birchmount
Jun-10
CompletedJul-10
Pending
E. Lipnicki
Page 6
Performance Measurement Summary
Action Plan
Quality of Care Committee reviews critical incident reports at each meeting and tracks status of recommendations
C. Hendriks Oct-10 Ongoing
Risk Management making regular report on incident trends and critical incidents quarterly to MAC C. Hendriks Oct-10 Ongoing
Monthly reports provided to each PSG director Performance & Decision Support Apr-10 OngoingStatusDate InitiatedLeadInitiative
Strategic DirectionQ4 2010/11 (projected based on Jan-Feb 2011)
Risk Ratingn/a
Analysis
SignificanceTo track trends in adverse events in order to identify and implement necessary improvement plans.
TargetTSH Target - 490, higher value is desired. The target for this indicator has been established as a 5% increase from the corresponding quarter in the previous fiscal year.
Time FrameSource
TSH is currently meeting target in this quarter. The experience in Canadian and U.S. hospitals is that adverse events are underreported and it can be assumed that TSH is no different. Therefore, the objective is to increase incident reporting, as least in the short term.
CHART PLACEHOLDER
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Number of incident reports completed (medication and non-medication)
DefinitionIncident reports are one mechanism to capture the occurence of an actual or potential adverse event in an organization (others include chart reviews, patient complaints, etc.). An online webbased system (S.A.F.E.) provided by RL Solutions is used at TSH to report patient, visitor and staff actual and potential adverse events as well as track follow-up actions for these events.
Our Patients
S.A.F.E. (rLSolutions)
403
467
576
521
626
705 73
0
743
0
100
200
300
400
500
600
700
800
Q1 Q2 Q3 Q4 (projected based on Jan-Feb 2011)
2009/10 2010/11 Target
Page 7
Performance Measurement Summary
Action Plan
Dr. S. Jackson Ongoing
Time Frame
The following initiatives are underway:• Mortality Chart Review (current)• Quality of Care Committee (Feb-10)• Face Sheet implemented Nov-10• Hospitalists 4 in place on 2 wards as of Feb-11
DefinitionThe ratio of actual in-hospital deaths to the expected number of in-hospital deaths for conditions that account for 80% of in-patient mortality. Where a HSMR score of 100 represents the actual number of deaths equal to the expected number of deaths. A number above 100 indicates a higher than expected number of deaths and a number below 100 indicates a lower than expected number of deaths.
SignificanceThis is a global indicator for patient safety and the quality of care provided within a facility.
TargetTSH Target - 100, lower value is desired.
Risk Ratingn/a
2010/11 (Apr-Dec)
Feb-10
Source
Hospital Standardized Mortality Ratio (HSMR)Our PatientsStrategic Direction
The Scarborough HospitalCorporate Balanced Scorecard
Indicator
The Canadian Institute for Health Information (CIHI)
Analysis
StatusDate InitiatedLead
CHART PLACEHOLDER
Initiative
The 2009/10 year-end TSH HSMR showed dramatic improvement with the publicly released value of 84. We now rank within the top 10 in the GTA and 4th amongst peer community hospitals.
137
129
131
127
112
112
80
75
122
120
114
114
105
97
88
73
132
126
124
122
109
106
84
74
0
20
40
60
80
100
120
140
160
2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 (Apr-Dec)
General Birchmount TSH Target
Page 8
Performance Measurement Summary
Action Plan
Continue with the development of a unit based hand hygiene program overseen by IPAC N. Vankoosingh Jul-10 In progressInitiative Lead Date Initiated Status
Source Surveillance and Case Finding
Definition The single most common way of transferring health care-associated infections (HAIs) in health care settings is on the hands of health care providers. Health care providers move from patient to patient and room to room while providing care and working in the patient environment. This movement provides many opportunities for the transmission of organisms on hands that can cause infections.
CHART PLACEHOLDER
SignificanceProper hand hygiene protects patients and providers and will reduce the spread of infections and the associated treatment costs, reduce hospital lengths of stay and readmissions, reduce wait times, and prevent deaths.
Target.Ontario Target - 90% Before and 90% After, higher value is desired.
Risk Ratingn/a
AnalysisDue to the lack of modified workers and the VRE issue, there were not enough audits done to report for Q3 at the General Campus. The data for the Birchmount Campus exceeds the target for After care.
Strategic Direction Our PatientsTime Frame Q4 2010/11
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Rate of hand hygiene compliance
90%
, n=8
20
97%
, n=8
79
94%
, n=2
334
98%
, n=2
430
81%
, n=3
40
90%
, n=3
84
98%
, n=6
44
99%
, n=6
55
90%
, n=1
715
94%
, n=1
818
90%
, n=4
63
96%
, n=4
91
93%
, n=1
464
98%
, n=1
534
92%
, n=4
049
96%
, n=4
248
85%
, n=8
03
89%
, n=8
75
0%
20%
40%
60%
80%
100%
120%
Before After Before After Before After
2008/09 2009/10 2010/11
General Campus Birchmount Campus TSH Target
Page 9
Performance Measurement Summary
Action PlanInitiative Lead Date Initiated Status
Sep-10
DefinitionThe Employee Opinion Survey measures employee satisfaction on various scales. Employee Commitment composite score is shown on the scorecard. Scores are out of 100. Commitment score is composed of average scores from 5 questions: i) Organization is great to work for ii) Proud to say part of organization iii) My values/organization's values are similar iv) Organization inspires best in you v) Glad chose organization over others.
Analysis
Scheduled for Fall 2011
Completed
CompletedIntroduce Pulse Survey to measure engagement (quarterly snapshot) Fall 2011
Mar-10
Employee Opinion Survey to be administered every 2 years, next full survey will be September 2010S. Rai-Lewis
SignificanceTo track trends in employee satisfaction in order to identify and implement necessary improvement plans.
All Hospital Average commitment scores for employees is 59.4% and Physician All Hospital Average for commitment is 43.1%. EOS increased by 13.1% and POS by 13.9%. Although we did not meet the target of 55% ,our data clearly indicates a statistically significant positive trend in commitment. Addressing prioritized areas of improvement both at the Corporate and unit level will continue to positively impact commitment scores going forward.
S. Rai-Lewis
TargetOntario Average - 59% for 2010/11 and 55% for 2008/09, higher value is desired.
Risk Ratingn/a
2010/11Time FrameSource
Violence in the Workplace- Organized polices; Code White, harassment, discrimination, code of conduct and violence in the workplace under one heading – Respect in The Workplace. Rollout of training on Bill 168 to be completed in June. Ongoing training through learning institiute
NRC Picker
CHART PLACEHOLDER
S. Rai-Lewis
Strategic Direction
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Employee Satisfaction survey results (Commitment composite score)Our People
37.5
%, n
=160
6 50.9
%, n
=159
0
0%
10%
20%
30%
40%
50%
60%
2008/09 2010/11
Commitment Score Target
Page 10
Performance Measurement Summary
Action Plan
Time FrameOur People
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Physician Satisfaction survey results (Commitment composite score)
Source NRC Picker
CHART PLACEHOLDER
SignificanceTo track trends in physician satisfaction in order to identify and implement necessary improvement plans.
DefinitionThe Physician Opinion Survey measures physician satisfaction on various scales. The physician commitment composite score is shown on the scorecard. Scores are out of 100. Commitment score is composed of average scores from 5 questions: i) Organization is great to work for ii) Proud to say part of organization iii) My values/organization's values are similar iv) Organization inspires best in you v) Glad chose organization over others.
Analysis
OngoingDr. S. JacksonOngoing
StatusDate InitiatedLeadApr-10
Initiative
Strategic Direction
Development of robust communication with family physicians Dr. S. Jackson Apr-10Performance review taking into account values including code of conduct
The 2010 survey shows dramatic improvement as compared to 2008. The 2010 commitment score of 42.7 is now comparable to the hospital average.
2010/11
TargetOntario Average - 43% for 2010/11 and 45% for 2008/09, higher value is desired.
Risk Ratingn/a
The development of Physician leadership award Apr-10Dr. S. Jackson
OngoingOngoingThe development of the The Clinical Services Plan
Dr. S. JacksonApr-10
28.8
%, n
=141
42.7
%, n
=151
0%
10%
20%
30%
40%
50%
60%
2008/09 2010/11
Commitment Score Target
Page 11
Performance Measurement Summary
Action Plan
Transition of clinical resource staff to the new Clinical Resource Leader role R. Seidman-Carlson Apr-10 CompletedInitiative Lead Date Initiated Status
Source Internal Tracking
DefinitionPercentage of clinical resource staff (i.e. nurse educators and nurse clinician) who have transitioned and are functioning in the new Clinical Resource Leader role.
CHART PLACEHOLDER
SignificanceModel of Care positions supports excellent care and full scope of practice and enhances partnerships between practice and operations.
Target100%
Risk Ratingn/a
AnalysisAll positions have been transitioned and all are functioning in the role.
Strategic Direction Our PeopleTime Frame 2010/11
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Percentage of defined Model of Care positions transitioned
100%
, n=2
1
0%
20%
40%
60%
80%
100%
120%
2010/11
% positions transitioned Target
Page 12
Performance Measurement Summary
Action PlanInitiative Lead Date Initiated StatusInitialization of Medical Directors performance and evaluations Dr. S. Jackson Apr-10 Ongoing
Source Internal Tracking
DefinitionPercentage of Medical Directors with completed annual performance evaluations. Percentage based on total number of Medical Directors in the hospital.
CHART PLACEHOLDER
SignificanceEmployee evaluation is important for development of staff and managers to be aware of employee development needs.
TargetInternal Target - 100%, higher value is desired.
Risk Ratingn/a
AnalysisPerformance evaluations are on track to be completed by the end of the fiscal year.
Strategic Direction Our PeopleTime Frame Q3 2010/11
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Percentage of Medical Directors with completed performance evaluations
80%
, n=8
0%
20%
40%
60%
80%
100%
120%
Q3 2010/11
% Medical Directors with completed evaluation Target
Page 13
Performance Measurement Summary
Action Plan
R. AnsteyLeadInitiative
2010/11 (Apr-Sept)Healthcare Indicator Tool (HIT)
DefinitionTotal equipment cost (including depreciation rental/lease and maintentance cost) as a percent of total hospital expense.
Time FrameSource
Expedite acquisition of major pieces of equipment included in 2010/11 Capital Plan Feb-11StatusDate Initiated
SignificanceTo track our investment in equipment and technology in comparison to our industry.
TargetLHIN Average - 5.9%, target value is desired.
Risk RatingMedium - Impact would be operational (i.e. quality).
Analysis
In progress
HIT indicator #17, Percentage of equipment cost to total expenseOur Programs, Plans and Partners
The Scarborough HospitalCorporate Balanced Scorecard
IndicatorStrategic Direction
Lack of investment in equipment and technology may impact quality of care and performance. Equipment depreciation has declined due to delay in acquisition of new equipment (i.e. CTs).
CHART PLACEHOLDER
6.2%
6.2%
5.6%
5.2% 5.
4%
5.2%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 (Apr-Sept)
% of equipment cost to total expense Target
Page 14
Performance Measurement Summary
Action Plan
Sep-10 Ongoing
Largest proportion of missed milestones were presentation of Business Cases. These presentations are scheduled for March 7
C. Flemming Feb-11 Ongoing
PMO Lead reviewing all project milestones to ensure they meet the milestone definition and that there are sufficient milestones to track the project. Feedback provided to project managers
J. Cox Oct-10 Ongoing
J. Cox Ongoing
Inventory of task timelines being development to guide future project plans (e.g. RFP development and positng, contract negotiation, hardware procurement)
J. Cox Oct-10 Ongoing
Sep-10Monthly status reports required from each project manager to report on project status, met and missed milestone, project risksPMO Advisory Committee Coach assigned to each project to provide advice on Status Report content C. Flemming
TargetInternal Target - 80%, higher value is desired.
Risk RatingMedium- Reputational, financial or operational risk.
Analysis
LeadInitiative
In Q3 2010/11, fourty-three milestones were being tracked by the PMO. In this quarter, 20 of 43 milestones have been met.
CHART PLACEHOLDER
StatusDate Initiated
SignificanceA measure of department performance, efficiency and planning.
Time FrameSource
Our Programs, Plans, and PartnersQ3 2010/11Eclipse project management application
DefinitionA number of initiatives for the department have been agreed upon at the outset of the fiscal year. Each initiative has milestones that must be achieved. This measure represents all milestones achieved for all initiatives as a percentage.
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Percentage of PMO project milestones metStrategic Direction
94%
, n=1
5
96%
, n=2
2
47%
, n=2
0
0%
20%
40%
60%
80%
100%
120%
Q1 2010/11 Q2 2010/11 Q3 2010/11
% milestones achieved Target
Page 15
Performance Measurement Summary
Action Plan
VP/ED Scorecards to be sent to PDS upon completion for publication on the PDS SharePoint site C. Flemming Aug-10 PendingC. Flemming Aug-10
Pending
VP/ED Scorecard SMT presentation schedule established
Discuss QIP and VP/ED Scorecards at March SMT meeting C. Flemming Feb-11
Performance & Decision Support
Analysis
SignificanceRoutine uploading of scorecards will facilitate regular review of the indicators and transparency to the staff and other departments.
StatusCompleted
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Percentage of Programs and Departments with performance indicator scorecards and action plans that are posted and updated quarterly on the Intranet
DefinitionA Corporate Scorecard (1) has been developed, along with scorecards for each VP/ED portfolio (7), PSG and clinical support department (12). This measure reflects whether the scorecards (including action plans) were published and posted on the SharePoint.
Q3 2010/11Time FrameSource
Strategic Direction Our Performance
CHART PLACEHOLDER
Lead
TargetInternal Target - 100%, higher value is desired.
Risk Ratingn/a
Initiative Date Initiated
A schedule has been developed for VP/ED scorecard reporting at the weekly Senior Management Team (SMT) meeting. The Performance & Decision Support PDS consultant is responsible for building and maintaining scorecards for their respective PSGs on a quarterly basis. There are a total of 20 Scorecards (1 Corporate, 7 VP/ED, and 12 PSG/Depart.).
85%
, n=1
7
75%
, n=1
5
75%
, n=1
5
0%
20%
40%
60%
80%
100%
120%
Q1 2010/11 Q2 2010/11 Q3 2010/11
% of posted scorecards Target
Page 16
Performance Measurement Summary
Action PlanLeadR. AnsteyQuarterly review by Senior Management Team to ensure a total margin of 0% or better is maintained In progressJul-10
Initiative StatusDate Initiated
Source Finance
SignificanceTo ensure the Hospital is operating in a balanced or surplus position.
TargetTSH Target - 0%, target value is desired.
Risk Ratingn/a
April to January result of 0.30% reflects a surplus of $690K for the first 9 months of 2010/11.
CHART PLACEHOLDER
Analysis
2010/11 (Apr-Jan)
DefinitionTotal margin is the percentage by which total revenues exceed or fall short of total expenses. A positive percent indicates an operating surplus position where a negative percent reflects an operating deficit position.
Time Frame
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Total marginStrategic Direction Our Performance
-2.00%
-1.50%
-1.00%
-0.50%
0.00%
0.50%
1.00%
2006/07 2007/08 2008/09 2009/10 2010/11 (Apr-Jan)
Total Margin Target
Page 17
Performance Measurement Summary
Action PlanInitiative Lead Date Initiated Status
Investigate Rehab patient day volumes R. Anstey, E. Lipnicki Aug-10 In progress
Risk Ratingn/a
SignificanceTrack volumes for the indicators in the Hospital's Accountability Agreement to ensure that we are meeting our MOHLTC commitments.
TargetTSH Target - 80%, higher value is desired.
In progressJul-10Continue to monitor financial results
Our Performance
FinanceSource
CHART PLACEHOLDER
AnalysisIn Q3 the rehab Patient days target has not been achieved as we are experiencing a decline in this service as patients are being discharged earlier and rehab is taking place on an outpatient basis or at a designated rehab facility. There are possible financial penalties associated with not meeting accountability agreement commitments.
R. Anstey
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Percentage of accountability agreement indicators achieved
Time FrameStrategic Direction
Q3 2010/11
DefinitionOverall percent achievement of 8 accountability agreement indicators: (Total Margin, Current Ratio, % FT Nurses, Weighted Cases, MH Patient Days, Rehab Patient Days, ER Visits, Amb Visits).
75%
, n=6
100%
, n=8
88%
, n=7
75%
, n=6 88
%, n
=7
88%
, n=7
0%
20%
40%
60%
80%
100%
120%
2007/08 2008/09 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11
% accountability agreement indicators achieved Target