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 Q4 Staff 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 Q4 HIT 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 period Yellow = Performance is below the target, however it has improved over the previous reporting period Green = 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 Direction Our 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 risk H = High reputational, financial or operational risk Risk Rating Legend L = Low reputational, financial or operational risk The Scarborough Hospital Corporate Balanced Scorecard Q3 2010/11 Page 1
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
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 Q4
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 Q4
HIT indicator #17, Percentage of equipment cost to total expense 5.2% 5.4% 5.9% R M 13
Number of standardized order sets usedQ1
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 Intranet75% 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 period
Yellow = Performance is below the target, however it has improved over the previous reporting period
Green = 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 Direction
Our 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 risk
H = High reputational, financial or operational risk
Risk Rating Legend
L = Low reputational, financial or operational risk
The Scarborough Hospital
Corporate Balanced Scorecard
Q3 2010/11
Page 1
Indicator
Current
Value
Previous
Value Target
Current
Status Risk Rating* Page
Our Patients: Create an environment of
Emergency Department Wait Time for High Acuity Visits - General Campus 19:35 15:12 8:00 R H A1
Emergency Department Wait Time for High Acuity Visits - Birchmount Campus 22:51 12:12 8:00 R H A2
Emergency Department Wait Time for Low Acuity Visits - General Campus 5:31 4:48 4:00 R H A3
Emergency Department Wait Time for Low Acuity Visits - Birchmount Campus 4:57 4:30 4:00 R H A4
Percent of CTAS 1&2 meeting 8 hour target 66% 71% 90% R H A5
Percent of CTAS 3 meeting 6 hour target 66% 73% 90% R H A6
Percent of CTAS 4&5 meeting 4 hour target 79% 84% 90% R H A7
Rate of Hospital Acquired C. difficile Associated Diarrhea 0.32 0.22 0.28 R M A8
Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia 0.00 0.00 0.02 G n/a A9
Rate of Hospital Acquired Vancomycin Resistant Enterococcus (VRE) Bacteraemia 0.00 0.00 0.00 G n/a A10
Rate of Central Line Infection (CLI) 1.48 0.61 0.75 R A11
Rate of Ventilator Associated Pneumonia (VAP) 0.00 0.76 1.46 G n/a A12
Rate of Timely Administration of Prophylactic Antibiotics - Primary Hip & Knee 98.0% 97.6% 96.1% G n/a A13
Wait Time - General Surgery 82 67 182 G n/a A14
Wait Time - Cancer Surgery 65 54 84 G n/a A15
Wait Time - Cataract Surgery 123 223 182 G n/a A16
Wait Time - Total Hip Replacement 123 151 182 G n/a A17
Wait time - Total Knee Replacement 106 153 182 G n/a A18
Wait Time - CT 20 23 28 G n/a A19
Wait 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 Legend
Red = 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 risk
Yellow = Performance is below the target, however it has improved over the previous reporting period M = Medium reputational, financial or operational risk
Green = 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 Hospital
Corporate 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 Addendum
Performance Measurement Summary
Action Plan
Initiative Lead Date Initiated Status
Strategic Direction Our Patients
The Scarborough Hospital
Corporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Emergency Department Wait Time for High Acuity Visits - General Campus
Definition
This indicator reports the 90th Percentile Wait time for all ED Admits with CTAS 1-5
and NonAdmits with CTAS 1-3.
CHART PLACEHOLDER
Significance
This indicator is associated with efficiency within the ED and within the hospital, as
well as with ED patient satisfaction.
Target
MOHLTC Target - 8:00, lower value is desired.
Risk Rating
High - 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 Ongoing
ED PIP initiated J. Phan Sep-09 Ongoing
Virtual CDU implemented Dr T. Chan Apr-10 Ongoing
Charge Nurse and Triage RN Education T. Reardon Mar-10 Ongoing
Rounding for Outcomes D. Edman Jun-10 Ongoing
Schedule to Demand D. Edman Jun-10 Completed
NP LTC B. Bickle Jun-10 Ongoing
Performance Huddles Leadership Team Jun-10 Ongoing
Schedule to Demand M. Tang Jan-11 Pending
ED PIP Kaizen Events S. Gilbert Aug-10 In progress
15
:54
, n=8
05
1
15
:31
, n=7
93
8
15
:32
, n=8
51
2
16
:47
, n=8
51
7
15
:48
, n=8
88
3
13
:12
, n=9
74
7
15
:12
, n=1
07
27
19
:35
, n=3
51
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 A1
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough Hospital
Corporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Emergency Department Wait Time for High Acuity Visits - Birchmount Campus
Definition
This indicator reports the 90th Percentile Wait time for all ED Admits with CTAS 1-5
and NonAdmits with CTAS 1-3.
CHART PLACEHOLDER
Significance
This indicator is associated with efficiency within the ED and within the hospital, as
well as with ED patient satisfaction.
Target
MOHLTC Target - 8:00, lower value is desired.
Risk Rating
High - 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 Ongoing
Laboratory Technologists G. Bajwa Sep-09 Ongoing
Charge Nurse and Triage RN Education L. Vanden Kroonenberg Mar-10 Ongoing
NP LTC
ED PIP initiated N. Alli, T. Osgood May-10 In progress
Virtual 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 Ongoing
Rounding for Outcomes
17
:02
, n=6
38
7
15
:30
, n=6
32
5
16
:45
, n=6
56
1
16
:31
, n=6
67
3
14
:06
, n=6
66
8
13
:36
, n=6
81
2
12
:12
, n=7
16
6
22
:51
, n=2
51
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 A2
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough Hospital
Corporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Emergency Department Wait Time for Low Acuity Visits - General Campus
Definition
This indicator reports the 90th Percentile Wait time for all NonAdmit with CTAS 4-5
visits.
CHART PLACEHOLDER
Significance
This indicator is associated with efficiency within the ED and within the hospital, as
well as with ED patient satisfaction.
Target
MOHLTC Target - 4:00, lower value is desired.
Risk Rating
High - 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
Ongoing
RPN 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 progress
Performance Huddles Leadership Team
06
:37
, n=5
22
0
05
:37
, n=5
47
7
06
:07
, n=5
32
5
05
:54
, n=4
48
7
05
:42
, n=4
77
9
05
:12
, n=4
48
1
04
:48
, n=3
71
3
05
:31
, n=1
24
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 A3
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough Hospital
Corporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Emergency Department Wait Time for Low Acuity Visits - Birchmount Campus
Definition
This indicator reports the 90th Percentile Wait time for all NonAdmit with CTAS 4-5
visits.
CHART PLACEHOLDER
Significance
This indicator is associated with efficiency within the ED and within the hospital, as
well as with ED patient satisfaction.
Target
MOHLTC Target - 4:00, lower value is desired.
Risk Rating
High - 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 progress
RPN Role D. Edman Jun-09 Ongoing
Performance Huddles Leadership Team Jun-10 Ongoing
Rounding for Outcomes D. Edman Jun-10 Ongoing
See and Treat Model of Care ED Staff Aug-10 In progress
06
:37
, n=3
90
5
05
:37
, n=3
89
4
06
:07
, n=3
81
1
05
:54
, n=3
27
1
05
:18
, n=3
98
0
05
:00
, n=3
95
0
04
:30
, n=3
97
3
04
:57
, n=1
18
8
0:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
Birchmount Target
Page A4
Performance Measurement Summary
Action Plan
Performance Huddles Leadership Team Jun-10 Ongoing
ED PIP Kaizen Events S. Gilbert Aug-10 In progress
Jun-10 OngoingNP LTC B. Bickle
Schedule to Demand D. Edman Jun-10 Completed
Rounding for Outcomes D. Edman Jun-10 Ongoing
Virtual CDU implemented Dr T. Chan Apr-10 Ongoing
Charge Nurse and Triage RN Education T. Reardon Mar-10 Ongoing
GEM D. Driver Oct-09 Ongoing
ED PIP initiated J. Phan Sep-09 Ongoing
Initiative Lead Date Initiated Status
Source MOHLTC Wait Times Website / NACRS
Definition
This 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
Significance
To ensure adequate patient access and flow within ED and hospital.
Target
MOHLTC Target - 90%, higher value is desired.
Risk Rating
High - There will be reputational impact of dissatisfied patients waiting in Emergency
Department and potential financial risk of losing Pay-for-Results funding.
Analysis
There 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 Patients
Time Frame Q4 2010/11 (Jan)
The Scarborough Hospital
Corporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Percent of CTAS 1&2 meeting 8 hour target
67
%, n
=19
12
68
%, n
=18
54
66
%, n
=17
73
64
%, n
=17
95
69
%, n
=20
45
70
%, n
=23
32
71
%, n
=27
87
67
%, n
=85
5
65
%, n
=12
16
68
%, n
=12
03
69
%, n
=12
28
66
%, n
=11
81
69
%, n
=12
03
73
%, n
=14
01
73
%, n
=14
13
65
%, n
=46
3
66
%, n
=31
28
68
%, n
=30
57
67
%, n
=30
01
65
%, n
=29
76
69
%, n
=32
48
71
%, n
=37
33
71
%, n
=42
00
66
%, n
=13
18
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
General Birchmount TSH Target
Page A5
Performance Measurement Summary
Action Plan
Performance Huddles Leadership Team Jun-10 Ongoing
ED PIP Kaizen Events S. Gilbert Aug-10 In progress
Jun-10 OngoingNP LTC B. Bickle
Schedule to Demand D. Edman Jun-10 Completed
Rounding for Outcomes D. Edman Jun-10 Ongoing
Virtual CDU implemented Dr T. Chan Apr-10 Ongoing
Charge Nurse and Triage RN Education T. Reardon Mar-10 Ongoing
GEM D. Driver Oct-09 Ongoing
ED PIP initiated J. Phan Sep-09 Ongoing
Initiative Lead Date Initiated Status
Source MOHLTC Wait Times Website / NACRS
Definition
This indicator reports the percentage of ED patients with CTAS 3 who completed
their visit (Registration to Leaving ED) within 6 hours.
CHART PLACEHOLDER
Significance
To ensure adequate patient access and flow within ED and hospital.
Target
MOHLTC Target - 90%, higher value is desired.
Risk Rating
High - There will be reputational impact of dissatisfied patients waiting in Emergency
Department and potential financial risk of losing Pay-for-Results funding.
Analysis
There 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 Patients
Time Frame Q4 2010/11 (Jan)
The Scarborough Hospital
Corporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Percent of CTAS 3 meeting 6 hour target
51
%, n
=26
04
60
%, n
=30
50
60
%, n
=33
99
60
%, n
=33
81
65
%, n
=37
84
72
%, n
=45
53
73
%, n
=48
77
67
%, n
=14
86
58
%, n
=25
63
63
%, n
=27
71
58
%, n
=27
21
61
%, n
=28
37
65
%, n
=31
30
67
%, n
=32
03
72
%, n
=36
98
66
%, n
=11
67
55
%, n
=51
67
61
%, n
=58
21
59
%, n
=61
20
60
%, n
=62
18
65
%, n
=69
14
70
%, n
=77
56
73
%, n
=85
75
66
%, n
=26
53
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
General Birchmount TSH Target
Page A6
Performance Measurement Summary
Action Plan
Kaizen Events S. Gilbert Aug-10 In progress
Performance Huddles Leadership Team Jun-10 Ongoing
Rounding for Outcomes D. Edman Jun-10 Ongoing
See and Treat Model of Care ED Staff Mar-10 In progress
ED-PIP initiated J. Phan, N. Velosos Sep-09 Ongoing
RPN Role D. Edman Jun-09 Ongoing
Initiative Lead Date Initiated Status
Source MOHLTC Wait Times Website / NACRS
Definition
This 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
Significance
To ensure adequate patient access and flow within ED and hospital.
Target
MOHLTC Target - 90%, higher value is desired.
Risk Rating
High - There will be reputational impact of dissatisfied patients waiting in Emergency
Department and potential financial risk of losing Pay-for-Results funding.
Analysis
There are challenges related to flow of patient treatment between major and minor
cases.
Strategic Direction Our Patients
Time Frame Q4 2010/11 (Jan)
The Scarborough Hospital
Corporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Percent of CTAS 4&5 meeting 4 hour target
General Campus Birchmount Campus TSH Ontario Avg.Target
Page A13
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough Hospital
Corporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Wait Time - General Surgery
Definition
Wait 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
Significance
A measure of access and efficiency for patients requiring these procedures.
Target
MOHLTC Target - 182, lower value is desired.
Risk Rating
n/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 Ongoing
Hire 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=2
79
84
, n=2
79
61
, n=3
87
67
, n=3
14
68
, n=4
75
75
, n=3
97
75
, n=4
15
87
, n=4
99
88
, n=5
24
83
, n=4
19
67
, n=4
57
82
, n=3
56
-
20
40
60
80
100
120
140
160
180
200
TSH Ontario Target
Page A14
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough Hospital
Corporate 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.
Definition
Wait 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
Significance
A measure of access and efficiency for patients requiring these procedures.
Target
MOHLTC Target - 84, lower value is desired.
Risk Rating
n/a
Analysis
Dec-10
Time Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPort
Status
Ongoing
Continue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Dec-10 Ongoing
Initiative Lead Date Initiated
Allocate OR time to services with wait time cases N. Rahim
43
, n=1
00
46
, n=1
59 6
0, n
=21
7
53
, n=2
34
50
, n=1
69
59
, n=1
92 7
4, n
=22
3
49
, n=2
21
57
, n=1
91
54
, n=1
73
65
, n=2
67
-
10
20
30
40
50
60
70
80
90
TSH Ontario Target
Page A15
Performance Measurement Summary
Action Plan
Significance
A measure of access and efficiency for patients requiring these procedures.
The Scarborough Hospital
Corporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Wait Time - Cataract Surgery
Strategic Direction Our Patients
Target
MOHLTC Target - 182, lower value is desired.
Time Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPort
Definition
Wait 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 Rating
n/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 Ongoing
Continue 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 progress
Allocate OR time to the Ophthalmology surgeons with wait times exceeding the WTIS target of 182 days N. Rahim Oct-10 In progress
15
7, n
=14
09
13
8, n
=14
23
14
5, n
=14
18
14
5, n
=14
53
15
0, n
=16
13
14
9, n
=13
25
15
5, n
=14
34
16
5, n
=11
34
19
7, n
=14
38
21
2, n
=13
68
22
3, n
=13
31
12
3, n
=12
42
-
50
100
150
200
250
TSH Ontario Target
Page A16
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough Hospital
Corporate 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.
Definition
Wait 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
Significance
A measure of access and efficiency for patients requiring these procedures.
Target
MOHLTC Target - 182, lower value is desired.
Risk Rating
n/a
Analysis
Dec-10
Time Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPort
Status
Ongoing
Continue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Oct-09 Ongoing
Initiative Lead Date Initiated
Allocate OR time to services with wait time cases N. Rahim
17
1, n
=52
11
7, n
=43
14
5, n
=61
13
0, n
=50
14
6, n
=77
13
1, n
=64
10
8, n
=87
11
4, n
=62
11
6, n
=74
12
4, n
=57
15
1, n
=63
12
3, n
=43
-
50
100
150
200
250
TSH Ontario Target
Page A17
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough Hospital
Corporate 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.
Definition
Wait 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
Significance
A measure of access and efficiency for patients requiring these procedures.
Target
MOHLTC Target - 182, lower value is desired.
Risk Rating
n/a
Analysis
Dec-10
Time Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPort
Status
Ongoing
Continue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Oct-09 Ongoing
Initiative Lead Date Initiated
Allocate OR time to services with wait time cases N. Rahim
19
2, n
=20
2
15
9, n
=18
1
14
5, n
=24
2
12
4, n
=22
1
11
7, n
=22
3
11
3, n
=20
2
11
4, n
=24
1
12
4, n
=23
6
12
4, n
=22
2
13
0, n
=15
9
15
3, n
=22
2
10
6, n
=14
4
-
50
100
150
200
250
TSH Ontario Target
Page A18
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough Hospital
Corporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Wait Time - CT
Definition
Wait time is defined as the 90th percentile number of days wait for CT diagnostic
scan.
CHART PLACEHOLDER
Significance
Track the wait time indicators to ensure that we are meeting our MOHLTC
commitments and meeting the needs of our patients.
Target
MOHLTC Target - 28, lower value is desired.
Risk Rating
n/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 Pending
Application 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 clerks
T. Jackson Sep-10 Pending
In progress
Wait time data entry training for booking clerks V. Winters Nov-09 Completed
Nov-09
34
, n=5
09
1
41
, n=4
75
7
32
, n=5
03
0
38
, n=5
10
5
38
, n=5
07
7
39
, n=5
17
6
36
, n=5
38
7
29
, n=5
16
9
21
, n=5
51
0
23
, n=5
17
7
23
, n=5
60
5
20
, n=3
96
8
-
5
10
15
20
25
30
35
40
45
50
TSH Ontario Target
Page A19
Performance Measurement Summary
Action Plan
Strategic Direction Our Patients
The Scarborough Hospital
Corporate Balanced Scorecard
Publicly Reported Patient Safety Indicators
Indicator Wait Time - MRI
Definition
Wait time is defined as the 90th percentile number of days wait for MRI diagnostic
scan.
CHART PLACEHOLDER
Significance
Track the wait time indicators to ensure that we are meeting our MOHLTC
commitments and meeting the needs of our patients.
Target
MOHLTC Target - 28, lower value is desired.
Risk Rating
Medium - 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 progress
Wait 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=1
84
4
64
, n=1
63
5
79
, n=1
74
4 10
1, n
=17
18
99
, n=1
84
4
10
3, n
=18
95
11
8, n
=22
40
13
3, n
=21
21
10
9, n
=20
28
10
7, n
=20
85
11
6, n
=21
32
99
, n=1
95
4
-
20
40
60
80
100
120
140
TSH Ontario Target
Page A20
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
Target
TSH target is 50 for ED and 73 for IP, higher value is desired. The target is based
on GTA average.
The Scarborough Hospital
Corporate Balanced Scorecard
Indicator
Sep-10
Significance
This 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 Patients
Q3 2010/11
NRC Picker
Risk Rating
High- Reputational, financial or operational risk.
Definition
Response 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
ED Score IP Score Target - GTA ED Avg Target - GTA IP Avg
Page 2
D. Edman and N. Alli
D. Edman and T. ReardonPatient friendly waiting room
General 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 appropriately
Birchmount Campus
• Re-design waiting room, triage and registration in process
• ED activity board in process
Fast track RAZ patients
General Campus:
• Elite RAZ staff
• Number system to ensure patients are aware of who is next in line
• Pull to RAZ waiting room
Birchmount 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 3
Performance Measurement Summary
Action Plan
Initiative Lead Date Initiated Status
In progress
Completed
IPAC 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.
Source
Q3 2010/11
Strategic Direction
CHART PLACEHOLDER
Significance
Provides 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.
Target
TSH 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 Rating
n/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.
Definition
Percentage of 19 publicly reported patient safety indicators that meet the provincial
targets.
Meditech, NACRS, IPAC, MOHLTC Wait Times Public Website
Completed
The Scarborough Hospital
Corporate Balanced Scorecard
Indicator Percentage of publicly reported patient safety indicators meeting the provincial target (see addendum)
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 risks
PMO Advisory Committee Coach assigned to each project to provide advice on Status Report content C. Flemming
Target
Internal Target - 80%, higher value is desired.
Risk Rating
Medium- 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
Significance
A measure of department performance, efficiency and planning.
Time FrameSource
Our Programs, Plans, and Partners
Q3 2010/11Eclipse project management application
Definition
A 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 Hospital
Corporate Balanced Scorecard
Indicator Percentage of PMO project milestones met
Strategic Direction
94
%, n
=15
96
%, n
=22
47
%, n
=20
0%
20%
40%
60%
80%
100%
120%
Q1 2010/11 Q2 2010/11 Q3 2010/11
% milestones achieved Target
Page 14
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 Pending
C. 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
Significance
Routine uploading of scorecards will facilitate regular review of the indicators and
transparency to the staff and other departments.
Status
Completed
The Scarborough Hospital
Corporate Balanced Scorecard
Indicator Percentage of Programs and Departments with performance indicator scorecards and action plans that are posted and updated quarterly on the Intranet
Definition
A 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
Target
Internal Target - 100%, higher value is desired.
Risk Rating
n/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
=17
75
%, n
=15
75
%, n
=15
0%
20%
40%
60%
80%
100%
120%
Q1 2010/11 Q2 2010/11 Q3 2010/11
% of posted scorecards Target
Page 15
Performance Measurement Summary
Action Plan
Lead
R. 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
Significance
To ensure the Hospital is operating in a balanced or surplus position.
Target
TSH Target - 0%, target value is desired.
Risk Rating
n/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)
Definition
Total 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 Hospital
Corporate Balanced Scorecard
Indicator Total margin
Strategic 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 16
Performance Measurement Summary
Action Plan
Initiative Lead Date Initiated Status
Investigate Rehab patient day volumes R. Anstey, E. Lipnicki Aug-10 In progress
Risk Rating
n/a
Significance
Track volumes for the indicators in the Hospital's Accountability Agreement to
ensure that we are meeting our MOHLTC commitments.
Target
TSH Target - 80%, higher value is desired.
In progressJul-10Continue to monitor financial results
Our Performance
FinanceSource
CHART PLACEHOLDER
Analysis
In 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 Hospital
Corporate Balanced Scorecard
Indicator Percentage of accountability agreement indicators achieved
Time Frame
Strategic Direction
Q3 2010/11
Definition
Overall percent achievement of 8 accountability agreement indicators:
(Total Margin, Current Ratio, % FT Nurses, Weighted Cases, MH Patient Days,