Page 1 Our 1st Priority (to 30-Jun-11) Indicator 1st Qtr Reported Current Value Previous Value Target Current Status Risk Rating* Page Percentage of publicly reported patient safety indicators meeting the provincial target (see addendum) 63% 63% 100% Y n/a 2 Number of incident reports completed (medication and non-medication) 768 730 490 G n/a 4 Percentage of staff and physicians educated in Mission, Vision and Values defined behaviours Q4 79% 75% G n/a 5 Employee Satisfaction survey results (Commitment composite score) 50.9% 37.5% 59% Y n/a 6 Physician Satisfaction survey results (Commitment composite score) 42.7% 28.8% 43% Y n/a 7 Percentage of defined Model of Care positions transitioned 100% 100% 100% G n/a 8 Percentage of leaders with completed performance evaluations Q4 21% 50% Y n/a 9 Percentage of Medical Directors with completed performance evaluations Q3 100% 80% 100% G n/a 10 Percentage of non-union staff with completed performance evaluations Q4 46% 50% Y n/a 11 Percentage of unionized staff with completed performance evaluations Q4 6% 30% Y n/a 12 Percentage of leaders educated in LEAN methodology Q4 17% 100% Y n/a 13 HIT indicator #17, Percentage of equipment cost to total expense 5.2% 5.4% 5.9% R M 14 Number of standardized order sets used Q1 2011/12 Percentage of Clinical Service Plan (CSP) recommendations implemented Q4 2011/12 100% Percentage of PMO project milestones met 40% 47% 80% R L 15 Percentage of Programs and Departments with performance indicator scorecards and action plans that are posted and updated quarterly on the Intranet 65% 75% 100% R L 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 M = Medium reputational, financial or operational risk H = High reputational, financial or operational risk Risk Rating Legend L = Low reputational, financial or operational risk 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. Our Performance: Create an accountable, high performing organization that delivers measureable results. The Scarborough Hospital Corporate Balanced Scorecard Q4 2010/11 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. Vision: To be recognized as Canada’s leader in providing the best healthcare for a global community. Our People: Be the first choice for motivated, talented people who are inspired to deliver and support excellent care in a diverse environment.
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Page 1
Our 1st Priority (to 30-Jun-11) Indicator
1st Qtr Reported
Current Value
Previous Value Target
Current Status
Risk Rating* Page
Percentage of publicly reported patient safety indicators meeting the provincial target (see addendum) 63% 63% 100% Y n/a 2
Number of incident reports completed (medication and non-medication) 768 730 490 G n/a 4
Percentage of staff and physicians educated in Mission, Vision and Values defined behaviours Q4 79% 75% G n/a 5
Percentage of defined Model of Care positions transitioned 100% 100% 100% G n/a 8
Percentage of leaders with completed performance evaluations Q4 21% 50% Y n/a 9
Percentage of Medical Directors with completed performance evaluations Q3 100% 80% 100% G n/a 10
Percentage of non-union staff with completed performance evaluations Q4 46% 50% Y n/a 11
Percentage of unionized staff with completed performance evaluations Q4 6% 30% Y n/a 12
Percentage of leaders educated in LEAN methodology Q4 17% 100% Y n/a 13
HIT indicator #17, Percentage of equipment cost to total expense 5.2% 5.4% 5.9% R M 14
Number of standardized order sets used Q1 2011/12
Percentage of Clinical Service Plan (CSP) recommendations implemented Q4 2011/12
100%
Percentage of PMO project milestones met 40% 47% 80% R L 15
Percentage of Programs and Departments with performance indicator scorecards and action plans that are posted and updated quarterly on the Intranet 65% 75% 100% R L 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
M = Medium reputational, financial or operational riskH = High reputational, financial or operational risk
Risk Rating LegendL = Low reputational, financial or operational risk
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.
Our Performance: Create an accountable, high performing organization that delivers measureable results.
The Scarborough HospitalCorporate Balanced Scorecard
Q4 2010/11
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.Vision: To be recognized as Canada’s leader in providing the best healthcare for a global community.
Our People: Be the first choice for motivated, talented people who are inspired to deliver and support excellent care in a diverse environment.
Reported Current Value Previous Value 2010/11 Target Current Status Risk Rating*2011/12 QIP
Target Page
1. Rate of Hospital Acquired C. difficile Associated Diarrhea (CDI) QIP / PRPSI Safety 2 0.42 0.21 0.33 R 0.28 A12. Rate of Central Line Infection (CLI) QIP / PRPSI Safety 1 1.48 0.00 0.79 R L 1.93 A23. Rate of Ventilator Associated Pneumonia (VAP) QIP / PRPSI Safety 2 0.00 0.61 1.33 G n/a 1.46 A34. Rate of hand hygiene compliance before initial patient/patient environment contact QIP Safety 2 83% 93% 90% R L 90% A45. Rate of hand hygiene compliance after patient/patient environment contact 90% 100% 90% G n/a A46. Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia PRPSI 0.00 0.00 0.02 G n/a A57. Rate of Hospital Acquired Vancomycin Resistant Enterococcus (VRE) Bacteraemia PRPSI 0.00 0.00 0.00 G n/a A68. Rate of Timely Administration of Prophylactic Antibiotics - Primary Hip PRPSI 100.0% 97.1% 96.1% G n/a A79. Rate of Timely Administration of Prophylactic Antibiotics - Primary Knee PRPSI 96.6% 97.7% 96.1% G n/a A8
10. WHO surgical checklist compliance 100% 100% 98% G n/a A911. Hospital Standardized Mortality Ratio (HSMR) QIP Effectiveness 2 74 84 100 G n/a 100 A1012. 30 day readmission rate to any facility - All tracked CMGs QIP Effectiveness 2 14.5% 14.5% 14.5% G n/a 14.5% A1113. Percentage of ALC days QIP / HSAA Effectiveness 1 15.9% 12.2% 12.2% R H 12.2% A1214. Emergency Department Wait Time for High Acuity Visits - General Campus PRPSI 17:02 15:12 8:00 R H A1415. Emergency Department Wait Time for High Acuity Visits - Birchmount Campus PRPSI 20:24 12:12 8:00 R H A1516. Emergency Department Wait Time for Low Acuity Visits - General Campus PRPSI 5:16 4:48 4:00 R H A1617. Emergency Department Wait Time for Low Acuity Visits - Birchmount Campus PRPSI 4:55 4:30 4:00 R H A1718. Admitted patient treated within the LOS target of less than 8 hours - General Campus P4R 30% 32% 31% R H A1819. Admitted patient treated within the LOS target of less than 8 hours - Birchmount Campus P4R 27% 34% 36% R H A1920. Non-admitted high acuity patients treated within their respective targets of <=8 hours - General Campus P4R 91% 90% 87% G n/a A2021. Non-admitted high acuity patients treated within their respective targets of <=8 hours - Birchmount Campus P4R 89% 91% 90% R H A2122. Non-admitted low acuity patients treated within their respective targets of <=4 hours - General Campus P4R 85% 81% 81% G n/a A2223. Non-admitted low acuity patients treated within their respective targets of <=4 hours - Birchmount Campus P4R 81% 83% 77% G n/a A2324. 90th percentile physician initial assessment time - General Campus PRPSI 4:21 4:35 4:06 Y n/a A2425. 90th percentile physician initial assessment time - Birchmount Campus PRPSI 3:40 3:06 3:48 G n/a A2526. 90th Percentile ER Lengh of Stay for Admitted Patients QIP / HSAA Access 1 44:14 36:43 25:00 R H 25:00 A2627. 90th Percentile ER Length of Stay for Complex Condition Patients QIP / HSAA Access 1 8:01 8:19 8:00 Y n/a 8:00 A2728. Wait Time - General Surgery HSAA / PRPSI 76 67 182 G n/a A2829. Wait Time - Cancer Surgery HSAA / PRPSI 53 54 84 G n/a A2930. Wait Time - Cataract Surgery HSAA / PRPSI 120 225 182 G n/a A3031. Wait Time - Total Hip Replacement HSAA / PRPSI 131 151 182 G n/a A3132. Wait time - Total Knee Replacement HSAA / PRPSI 108 153 182 G n/a A3233. Wait Time - CT HSAA / PRPSI 19 23 28 G n/a A3334. Wait Time - MRI HSAA / PRPSI 97 116 28 Y n/a A3435. Patient satisfaction - Overall Impression: Emergency Department QIP Patient-Centred 1 54.5 46.7 50 G n/a 50 A3536. Patient satisfaction - Overall Impression: In-patients QIP Patient-Centred 1 59.2 66.3 70 R H 70 A3637. Repeat Unplanned Emergency Visited within 30 Days for Mental Health Conditions HSAA Q1 2011/1238. Repeat Unplanned Emergency Visited within 30 Days for Substance Abuse Conditions HSAA Q1 2011/12
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Our Patients
Indicator
39. Total margin QIP / HSAA Effectiveness 1 0.04% -0.31% 0% G n/a 0% A3840. Current Ratio HSAA 0.34 0.39 0.39 R M A3941. Total weighted cases (Inpatient and Day Surgery) HSAA 42,144 43,027 40,712 G n/a A4042. Mental Health Patient Days HSAA 15,970 15,425 15,000 G n/a A4143. Rehab Patient Days HSAA 2,397 3,221 3,530 R M A4244. Emergency Visits HSAA 103,351 99,915 98,000 G n/a A4345. Ambulatory Visits (excluding ER) HSAA 306,954 303,662 294,773 G n/a A4446. Total Hip and Knee Replacement HSAA 1,257 1,275 1,225 G n/a A4547. Cataract Surgeries HSAA 5,756 5,894 5,815 R M A4648. Computed Tomography (CT) HSAA 8,037 8,352 7,245 G n/a A4749. Magnetic Resonance Imaging (MRI) HSAA 6,225 6,123 5,657 G n/a A48
* Risk rating only completed for indicators that are not meeting the target and have not improved over the prior reporting period
Current Status Legend: Priority Legend
Risk Rating Legend Priority 2 - Moderate priority: • Current performance just below “benchmark” (if one exists) or below long term goal; room for improvement
Priority 3 - Lower priority: • Current performance at/above” benchmark”, provincial rate or long term goal • Organizational priority
L = Low reputational, financial or operational risk
M = Medium reputational, financial or operational risk
H = High reputational, financial or operational risk
Mission: To provide an outstanding care experience that meets the unique needs of each and every patient.Values: I ntegrity, C ompassion, A ccountability, R espect, E xcellence
• Current performance below “benchmark” (if one exists) or below long term goal; significant improvements requ • Aligned with organizational priorities/strategic plan, defined accreditation priority or recommendation, funding tied to initiative, aligned with government agenda
• Aligned with organizational priorities/strategic plan, defined accreditation priority or recommendation, funding tied to initiative, aligned with government agenda
Vision: To be recognized as Canada’s leader in providing the best healthcare for a global community.
Our Performance
Priority 1 - Highest priority 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
Page A1
Performance Measurement Summary
Action Plan
August 2011Source Surveillance and Case Finding
Strategic Direction Our Patients
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.C. difficile is communicable. It can live in the environment and on other surfaces. Rigorous cleaning regimes, patient isolation and hand washing are some of the strategies used to combat C. difficile.
TargetOntario Average - 0.33, lower value is desired.
Risk Ratingn/a
n/a n/a
AnalysisQIP use rate for January to December 2010. 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.
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator QIP - Rate of Hospital Acquired C. difficile Associated Diarrhea
Time Frame
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current StatusIndicator meeting or exceeding target, no action plan required n/a
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
0.25
, n=2
0.24
, n=2
0.47
, n=4
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
0.85
, n=5
0.17
, n=1
0.34
, n=2
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
0.50
, n=7
0.21
, n=3
0.42
, n=6
-
0.20
0.40
0.60
0.80
1.00
1.20
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
Jun
11
Jul 1
1
Aug
11
General Campus Birchmount Campus
TSH Ontario Average per 1,000 patient-days
TSH Rolling 12-month Average QIP Reported Value=0.26
Page A2
Performance Measurement Summary
Action Plan
Data collection in progress
Source
Date Initiated
Mar-11
Apr-10
Expanded data collection to include the program that the hemodialysis patients are coming from, type of line being used, and CLI reduction interventions such as the use of chlorhexidine dressing and bath to investigate higher rate of CLI in the hemodialysis population by Q2 of 2011/12
H. Clasky, R. Lovinsky, IPAC
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 - 0.79, lower value is desired.
Risk RatingLow - 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.
AnalysisQIP use rate for January to December 2010. There has been a marked improvement to the number of CLI cases in 2010/11 at the General Campus. CLI strategies to standardize processes across the campuses is showing improvements in the rates. There is lower rate of infection associated with PICC, therefore the use of PICC has been increased.
Surveillance and Case Finding
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator QIP - Rate of Central Line Infection (CLI)
Monthly monitoring of insertions and maintenance Bundle which includes hand hygiene, maximal barrier precautions, and chlorhexidine skin antisepsis and optimal catheter side selection to adhere the compliance of 90% to decrease rate of CLI for the next quarter
H. Clasky, D. Rose, P. Tamlin, R. Lovinsky, C. Shelton
Monthly audits
Strategic Direction Our PatientsTime Frame Q1 2011/12
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current Status
TSH Rolling 12-month Average QIP Reported Value=1.76
Page A3
Performance Measurement Summary
Action Plan
Strategic Direction Our PatientsTime Frame Q1 2011/12
Date Initiatedn/a
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
Source Surveillance and Case Finding
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 - 1.33, lower value is desired.
Risk Ratingn/a
AnalysisQIP use rate for January to December 2010. There were zero VAP case identified in the Q4. Currently meeting target.
Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator QIP - 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.
TSH Rolling 12-month Average QIP Reported Value=1.22
Page A4
Performance Measurement Summary
Action Plan
Source
Date InitiatedMar-11
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 RatingLow- Reputational, financial or operational risk.
AnalysisQIP use rate for 2009/10, only for before patient contact. Due to the lack of hand hygiene auditors and the VRE issue, there were not enough audits done to report for Q3 at the General Campus. In Q4 IPAC trained unit based auditors to carryout the audits to meet mandatory reporting requirements. The results of the before compliance are below TSH target; however, well above the Ontario average of 72.17%.
Surveillance and Case Finding
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator QIP - Rate of hand hygiene complianceStrategic Direction Our PatientsTime Frame Q1 2011/12
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusDevelopment of a audit process to monitor unit based hand hygiene audits and program overseen by IPAC and Decision Support. Monthly audit to observe number of times hand hygiene performed before patient contact.
IPAC In progress, on a monthly basis
95%
, n=5
7
97%
, n=5
8
100%
, n=7
88%
, n=7
0%, n
=0
0%, n
=0
0%, n
=0
0%, n
=0
0%, n
=0
0%, n
=0
81%
, n=2
68
90%
, n=3
01
84%
, n=3
34
88%
, n=3
54
85%
, n=1
063
92%
, n=1
180
87%
, n=3
60
96%
, n=3
92
96%
, n=2
5
96%
, n=2
5
93%
, n=5
2
100%
, n=5
6
93%
, n=6
2
90%
, n=6
0
85%
, n=3
91
89%
, n=4
12
85%
, n=1
070
92%
, n=1
187
87%
, n=3
60
96%
, n=3
92
96%
, n=2
5
96%
, n=2
5
93%
, n=5
2
100%
, n=5
6
83%
, n=3
30
90%
, n=3
61
0%
20%
40%
60%
80%
100%
120%
140%
Before After Before After Before After Before After Before After Before After
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 PLACEHOLDER
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.
0.00
, n=0
0.00
, n=0
0.04
, n=1
0.04
, n=1
0.00
, n=0
0.00
, n=0
0.04
, n=1
0.00
, n=0
0.00
, n=0
0.04
, n=1
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.
02, n
=1
0.02
, n=1
0.02
, n=1
0.00
, n=0
0.00
, n=0 0.
02, n
=1
0.00
, n=0
0.00
, n=0 0.
02, n
=1
0.00
0.02
0.04
0.06
0.08
0.10
0.12
0.14
0.16
General Campus Birchmount Campus
TSH Ontario Average per 1,000 patient-days
TSH Rolling 12-month Average
Page A6
Performance Measurement Summary
Action Plan
Time Frame Q1 2011/12
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
AnalysisThere have been no reportable cases of VRE bacteraemia despite increased numbers of VRE colonized patients since April 2010.
Source
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.
Surveillance and Case Finding
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Rate of Hospital Acquired Vancomycin Resistant Enterococcus (VRE) BacteraemiaStrategic Direction Our Patients
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a
Date Initiatedn/a
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 A7
Performance Measurement Summary
Action Plan
Strategic Direction Our PatientsTime Frame Q4 2010/11
Date Initiatedn/a
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
Source Medical Systems Management (OR System)
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.
TargetOntario Average - 96.1%, higher value is desired.
Risk Ratingn/a
AnalysisAll surgeons’ offices now have pre-printed orders. Work continues on ensuring a good process for improvement on this indicator. The drop at General was due to two cases where the patient did not receive a prophylactic antibiotic within the appropriate recommended time. One case was delayed because of an earlier case running late and the second was delayed because there was a delay in the turnover of the operating room. TSH continues to exceed GTA average.
Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Rate of Timely Administration of Prophylactic Antibiotics - Primary Hip
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.
Strategic Direction Our PatientsTime Frame Q4 2010/11
Date Initiatedn/a
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
Source Medical Systems Management (OR System)
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.
TargetOntario Average - 96.1%, higher value is desired.
Risk Ratingn/a
AnalysisAll 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.
Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Rate of Timely Administration of Prophylactic Antibiotics - Primary Knee
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.
DefinitionPercentage of cases carried out with checklist. Based on total number of surgical cases performed. The Surgical Safety Checklist is a one-page list of 26 of the most common tasks and items that operating room teams carry out to ensure patient safety.
CHART PLACEHOLDER
SignificanceOriginally developed as a tool to support patient care though professional preparation and teamwork, the consistent use of this checklist has been shown to reduce the rates of death and complications associated with surgical care.
Surgery implemented surgical check list in February 2010 at the General Campus and in March 2010 at the Birchmount Campus. Internal reporting of this indicator took place in April 2010. Public reporting of this indicator started in June 2010.
Target Ontario SETP Average - 98%, higher value is desired.
Risk Ratingn/a
Analysis
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator WHO surgical checklist complianceStrategic Direction Our PatientsTime Frame February 2011
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/an/a
QIP use HSMR for 2009/10. 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.
CHART PLACEHOLDER
SignificanceThis is a global indicator for patient safety and the quality of care provided within a facility.
Analysis
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.
General Birchmount TSH Target QIP Reported Value=84
Page A11
Performance Measurement Summary
Action Plan
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator QIP - 30 day readmission rate to any facility - All tracked CMGs
SignificanceReadmission rates have been used as a measure of the quality of inpatient care and discharge planning; e.g. successful transition to effective community resources.
QIP use percent for Q1 2010/11. We will monitor readmission rate and investigate the factors that resulted in need for readmission.
n/a
MOHLTC Website
Analysis
DefinitionThe number of patients readmitted to any facility for non-elective inpatient care within 30 days of discharge. This is compared to the number of expected non-elective readmissions using data from all Ontario acute hospitals. These are for acute inpatients in the specified CMGs for Stroke, COPD, CHF, Cardiac, pneumonia, diabetes and GI; with age restrictions in some of the CMGs. The data excludes acute transfers and patient sign-out against medical advice.
Date Initiated
Risk Ratingn/a
TargetInternal Target - 14.5%, this is the Expected Readmission rate for TSH average for 2009 calendar year. Expected Readmission is determined by looking at CMG, age, gender, prior hospitalizations, quarterly seasonality and comorbidity. Lower value is desired.
Source
Current StatusIndicator meeting or exceeding target, no action plan required n/a n/aSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
Risk RatingHigh- Reputational, financial or operational risk.
QIP use percent for Q2 2010/11. ALC patient days in comparison to the acute patient days is above target for Q4 2010/11. Ongoing initiative results will result in better processes to disposition patients to a more appropriate setting.
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
SignificanceThis indicator identifies barriers to alternative placement and monitor the prevalence of conditions treated with Alternate Level of Care (ALC) status.
TargetCELHIN Target - 12.2%, target value is desired.
Analysis
Strategic Direction Our PerformanceTime Frame Q4 2010/11 Source Health Records - DAD
DefinitionThe percentage of patient days awaiting alternative care in acute bed, excluding newborns.
CHART PLACEHOLDER
Jan-11
Indicator QIP - Percentage of ALC patients days/patient days in Acute beds
Date Initiated
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Current StatusThe Home First Initiative with CCAC will reduce the number of ALC-LTC patients by jointly reviewing all patients for potential to return home prior to ALC designation on a daily basis. All ALC-LTC alerts will be reviewed weekly by a joint committee with CCAC/CCS to identify alternate or preventable strategies to becoming ALC. 100% of all ALC-LTC alerts will be reviewed
N. Veloso, S.Greenwood, J. Miller
Ongoing, processes and meetings all in place as completed
April 2011 (inclusion of weekly performance monitoring)
Interprofessional daily bullet rounds on inpatient units introduced through Patient Flow PIP initiative enables improved discharge coordination to decrease length of stay for patients and avoid ALC. LOS and ALC case metrics on the DART tracker are reviewed during bullet rounds weekly on all medicine units to identify improvement strategies and action plans. 100% of Medicine inpatient units (General and Birchmount) will hold rounds 5/7 days/week
N. Veloso, L. Kane, M. DePaulsen, S. Johnson, T.Early
Ongoing
The GAIN clinic will provide timely geriatric assessments and interventions for frail seniors to facilitate earlier discharge from hospital and optimize patients returninig home upon discharge. The number of post discharge referrals to the GAIN clinic are reviewed weekly. 30% of GAIN referrals will target frail seniors being discharged from hospital in 2011/12
D. Driver, N. Veloso Completed implementation
The Geriatric Activation Program (GAP) provides enhanced therapy and activation for frail seniors upon admission to a hospitalist unit to optimize discharge home again and avoid ALC. The number of GAP referrals are tracked through meditech system for those paitents received enhanced therapy services. The GAP will provide service to 300 patients on the 2 hospitalist units in 2011/12
L. Kane, A. Sideris, N. Veloso
Completed implementationJan-11
Jan-11
Page A14
Performance Measurement Summary
Action PlanLead
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.
Current StatusMobile Admission Team (MAT) to be implemented June 2011
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.
CHART PLACEHOLDER
SignificanceThis indicator is associated with efficiency within the ED and within the hospital, as well as with ED patient satisfaction.
Analysis
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Emergency Department Wait Time for High Acuity Visits - General Campus
Source
Strategic Direction Our PatientsTime Frame
Apr-11
MAT ensure available bed ready (ABR) to in-patient unit transfer time of 45 minutes MAT Not meeting target currently, as MAT develops will review processes and targets
Admitted Mental Health patients to in-patient bed within 8 hours by September 2011
Q4 2010/11
S.Engels, A.MacKinnon
Implementing role change for Crisis Team – from consultant to patient flow coordinator
MOHLTC Wait Times Website / NACRS
DefinitionThis indicator reports the 90th Percentile Wait time for all ED Admits with CTAS 1-5 and NonAdmits with CTAS 1-3.
May-11
Developing terms of reference by June 2011; site visit to Sunnybrook May 2011; hire manager of patient flow and access June 2011
Patient Flow and Access Steering Committee implemented by June 30, 2011 A.MacKinnon
Jun-11
Collect and analyze data for specialist consultant time to ED by April 1, 2011 A.MacKinnon, N.Mills Break down consultant time data to request date/time and arrival date/time by May 2011; complete root cause analysis on May data in June 2011
N.Veloso, A.MacKinnon Funding approved by CELHIN April 2011; post position by May 2011 with interview and hire June 2011
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
17:0
2, n
=104
94
0:00
2:00
4:00
6:00
8:00
10:00
12:00
14:00
16:00
18:00
20:00
22:00
24:00
26:00
28:00
90th percentile Target TSH Median TSH Average
Page A15
Performance Measurement Summary
Action Plan
May-11
Apr-11
Apr-11
DefinitionThis indicator reports the 90th Percentile Wait time for all ED Admits with CTAS 1-5 and NonAdmits with CTAS 1-3.
CHART PLACEHOLDER
TargetMOHLTC Target - 8:00, lower value is desired.
Risk Ratingn/a
AnalysisThere are challenges related to specialty consultations and Diagnostic Imaging procedures.
MOHLTC Wait Times Website / NACRS
Apr-11
Patient Flow and Access Steering Committee implemented by June 30, 2011
Source
Date Initiated
Jun-11
A.MacKinnon Developing terms of reference by June 2011; site visit to Sunnybrook May 2011; hire manager of patient flow and access June 2011
Collect and analyze data for specialist consultant time to ED by April 1, 2011 A.MacKinnon, N.Mills
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Emergency Department Wait Time for High Acuity Visits - Birchmount CampusStrategic Direction Our PatientsTime Frame Q4 2010/11
Implementing role change for Crisis Team – from consultant to patient flow coordinator
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusMobile Admission Team (MAT) to be implemented June 2011 N.Veloso, A.MacKinnon Funding approved by CELHIN April 2011; post position
by May 2011 with interview and hire June 2011
SignificanceThis indicator is associated with efficiency within the ED and within the hospital, as well as with ED patient satisfaction.
Break down consultant time data to request date/time and arrival date/time by May 2011; complete root cause analysis on May data in June 2011
MAT ensure available bed ready (ABR) to in-patient unit transfer time of 45 minutes MAT Not meeting target currently, as MAT develops will review processes and targets
Admitted Mental Health patients to in-patient bed within 8 hours by September 2011 S.Engels, A.MacKinnon
Action PlanSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusAll Rapid Assessment Zone (RAZ) patients will have an ALOS of 3.5 hours at the Birchmount Campus and 4.0 hours at the General Campus by September 2011
Date Initiated
May-11
Apr-11D.Edman, T.Reardon, N.Alli
1. Implemented an elite RAZ team April 20112. Hours of operation changed from 12 hours to 24 hours May 2011
RAZ dedicated physician shift to be implemented in October 2011
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Emergency Department Wait Time for Low Acuity Visits - General Campus
Source
Strategic Direction Our PatientsTime Frame Q4 2010/11
MOHLTC Wait Times Website / NACRS
DefinitionThis indicator reports the 90th Percentile Wait time for all NonAdmit with CTAS 4-5 visits.
TargetMOHLTC Target - 4:00, lower value is desired.
Risk Ratingn/a
CHART PLACEHOLDER
SignificanceThis indicator is associated with efficiency within the ED and within the hospital, as well as with ED patient satisfaction.
AnalysisThere are challenges related to flow of patient treatment between major and minor cases.
Dr. T.Chan Currently recruiting, interviewing and preparing for appointment for October 2011
Through the implementation of a Geriatric Mental Health program, the ED LOS of elders with delirium, dementia and depression will be < 8 hours by December 2011
E.Laine, S.Vellani 1. Program approved by CE LHIN April 20112. Implementation team struck May 2011
May-11
6:37
, n=5
220
5:37
, n=5
477
6:07
, n=5
325
5:54
, n=4
487
5:42
, n=4
779
5:12
, n=4
481
4:48
, n=3
713
5:16
, n=3
520
0:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
90th percentile Target TSH Median TSH Average
Page A17
Performance Measurement Summary
Action Plan
May-11
Date Initiated
May-11
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
Time Frame
Apr-11
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 Ratingn/a
AnalysisThere are challenges related to flow of patient treatment between major and minor cases.
Q4 2010/11Source MOHLTC Wait Times Website / NACRS
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Emergency Department Wait Time for Low Acuity Visits - Birchmount CampusStrategic Direction Our Patients
Through the implementation of a Geriatric Mental Health program, the ED LOS of elders with delirium, dementia and depression will be < 8 hours by December 2011
E.Laine, S.Vellani 1. Program approved by CE LHIN April 20112. Implementation team struck May 2011
Current StatusAll Rapid Assessment Zone (RAZ) patients will have an ALOS of 3.5 hours at the Birchmount Campus and 4.0 hours at the General Campus by September 2011
D.Edman, T.Reardon, N.Alli
1. Implemented an elite RAZ team April 20112. Hours of operation changed from 12 hours to 24 hours May 2011
RAZ dedicated physician shift to be implemented in October 2011 Dr. T.Chan Currently recruiting, interviewing and preparing for appointment for October 2011
6:37
, n=3
905
5:37
, n=3
894
6:07
, n=3
811
5:54
, n=3
271
5:18
, n=3
980
5:00
, n=3
950
4:30
, n=3
973
4:55
, n=3
402
0:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
90th percentile Target TSH Median TSH Average
Page A18
Performance Measurement Summary
Action Plan
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Admitted patient treated within the LOS target of less than 8 hours - General CampusStrategic Direction Our PatientsTime Frame March 2011Source NACRS
DefinitionPercent of admitted patient treated within the LOS target of less than or equal to 8 hours, measured from registration to leaving General Campus Emergency Department.
CHART PLACEHOLDER
SignificanceThis is to meet Pay-for-Results expectations. There could be funding impact if targets are not met.
TargetCELHIN Target - 31%, 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.
Analysis
Admitted Mental Health patients to in-patient bed within 8 hours by September 2011 S.Engels, A.MacKinnon
There are challenges related to discharge processes, bed turnover times, and bed availability. As a result of ED PIP, white boards, discharge huddles, and patient education the 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.
Date InitiatedMay-11
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusMobile Admission Team (MAT) to be implemented June 2011 N.Veloso, A.MacKinnon Funding approved by CELHIN April 2011; post position
by May 2011 with interview and hire June 2011MAT ensure available bed ready (ABR) to in-patient unit transfer time of 45 minutes MAT Not meeting target currently, as MAT develops will
review processes and targetsJun-11
Implementing role change for Crisis Team – from consultant to patient flow coordinator
Patient Flow and Access Steering Committee implemented by June 30, 2011 A.MacKinnon Developing terms of reference by June 2011; site visit to Sunnybrook May 2011; hire manager of patient flow and access June 2011
Collect and analyze data for specialist consultant time to ED by April 1, 2011 A.MacKinnon, N.Mills Break down consultant time data to request date/time and arrival date/time by May 2011; complete root cause analysis on May data in June 2011
Apr-11
Apr-11
Apr-11
29%
, n=1
54
20%
, n=1
17
28%
, n=1
64
17%
, n=1
04 22%
, n=1
11 28%
, n=1
54
27%
, n=1
49
22%
, n=1
28
24%
, n=1
34
26%
, n=1
41
27%
, n=1
46
25%
, n=1
33
21%
, n=9
8
24%
, n=1
17
20%
, n=1
27
22%
, n=1
30
32%
, n=1
63
30%
, n=1
97
0%
5%
10%
15%
20%
25%
30%
35%
40%
Percent Target
Page A19
Performance Measurement Summary
Action Plan
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Admitted patient treated within the LOS target of less than 8 hours - Birchmount CampusStrategic Direction Our PatientsTime Frame March 2011Source NACRS
DefinitionPercent of admitted patient treated within the LOS target of less than or equal to 8 hours, measured from registration to leaving Birchmount Campus Emergency Department.
CHART PLACEHOLDER
SignificanceThis is to meet Pay-for-Results expectations. There could be funding impact if targets are not met.
TargetCELHIN Target - 36%, 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.
Analysis
Admitted Mental Health patients to in-patient bed within 8 hours by September 2011 S.Engels, A.MacKinnon
There are challenges related to discharge processes, bed turnover times, and bed availability. As a result of ED PIP, white boards, discharge huddles, and patient education the 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.
Date InitiatedMay-11
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusMobile Admission Team (MAT) to be implemented June 2011 N.Veloso, A.MacKinnon Funding approved by CELHIN April 2011; post position
by May 2011 with interview and hire June 2011MAT ensure available bed ready (ABR) to in-patient unit transfer time of 45 minutes MAT Not meeting target currently, as MAT develops will
review processes and targetsJun-11
Implementing role change for Crisis Team – from consultant to patient flow coordinator
Patient Flow and Access Steering Committee implemented by June 30, 2011 A.MacKinnon Developing terms of reference by June 2011; site visit to Sunnybrook May 2011; hire manager of patient flow and access June 2011
Collect and analyze data for specialist consultant time to ED by April 1, 2011 A.MacKinnon, N.Mills Break down consultant time data to request date/time and arrival date/time by May 2011; complete root cause analysis on May data in June 2011
Apr-11
Apr-11
Apr-11
30%
, n=1
51
30%
, n=1
50 37%
, n=2
11
30%
, n=1
68
32%
, n=1
63
32%
, n=1
82
27%
, n=1
39
36%
, n=1
84
37%
, n=1
82
38%
, n=2
10
35%
, n=1
81
47%
, n=2
38
40%
, n=1
84
47%
, n=1
93
33%
, n=1
93
28%
, n=1
67
34%
, n=1
40
27%
, n=1
62
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Percent Target
Page A20
Performance Measurement Summary
Action Plan
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Non-admitted high acuity patients treated within their respective targets of <=8 hours - General CampusStrategic Direction Our PatientsTime Frame March 2011Source NACRS
DefinitionPercent of non-admit CTAS 1, 2 and 3 patients treated within 8 hours, measured from registration to leaving General Campus Emergency Department.
CHART PLACEHOLDER
SignificanceThis is to meet Pay-for-Results expectations. There could be funding impact if targets are not met.
TargetCELHIN Target - 87%, higher value is desired.
Risk RatingN/A
Analysis
Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Non-admitted high acuity patients treated within their respective targets of <=8 hours - Birchmount CampusStrategic Direction Our PatientsTime Frame March 2011Source NACRS
DefinitionPercent of non-admit CTAS 1, 2 and 3 patients treated within 8 hours, measured from registration to leaving Birchmount Campus Emergency Department.
CHART PLACEHOLDER
SignificanceThis is to meet Pay-for-Results expectations. There could be funding impact if targets are not met.
TargetCELHIN 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.
Analysis
Admitted Mental Health patients to in-patient bed within 8 hours by September 2011 S.Engels, A.MacKinnon
Consistently moving toward meeting our target. We have been close to target for last 8 months.
Date InitiatedMay-11
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusMobile Admission Team (MAT) to be implemented June 2011 N.Veloso, A.MacKinnon Funding approved by CELHIN April 2011; post position
by May 2011 with interview and hire June 2011MAT ensure available bed ready (ABR) to in-patient unit transfer time of 45 minutes MAT Not meeting target currently, as MAT develops will
review processes and targetsJun-11
Implementing role change for Crisis Team – from consultant to patient flow coordinator
Patient Flow and Access Steering Committee implemented by June 30, 2011 A.MacKinnon Developing terms of reference by June 2011; site visit to Sunnybrook May 2011; hire manager of patient flow and access June 2011
Collect and analyze data for specialist consultant time to ED by April 1, 2011 A.MacKinnon, N.Mills Break down consultant time data to request date/time and arrival date/time by May 2011; complete root cause analysis on May data in June 2011
Apr-11
Apr-11
Apr-11
83%
, n=1
,400
85%
, n=1
,493
85%
, n=1
,307
84%
, n=1
,348
85%
, n=1
,294
87%
, n=1
,586
88%
, n=1
,407
86%
, n=1
,561
87%
, n=1
,513
86%
, n=1
,439
89%
, n=1
,698
89%
, n=1
,494
89%
, n=1
,435
93%
, n=1
,488
91%
, n=1
,923
89%
, n=1
,710
91%
, n=1
,598
89%
, n=1
,764
0%
20%
40%
60%
80%
100%
Percent Target
Page A22
Performance Measurement Summary
Action Plan
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
We are currently meeting target. We have met or been close to target the past 10 months.
Indicator Non-admitted low acuity patients treated within their respective targets of <=4 hours - General CampusStrategic Direction Our Patients
SignificanceThis is to meet Pay-for-Results expectations. There could be funding impact if targets are not met.
Time Frame March 2011Source NACRS
DefinitionPercent of non-admit CTAS 4 and 5 patients treated within 4 hours, measured from registration to leaving General Campus Emergency Department.
CHART PLACEHOLDER
TargetCELHIN Target - 81%, higher value is desired.
Risk RatingN/A
Analysis
Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a
Date Initiatedn/a
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
76%
, n=1
,383
74%
, n=1
,376
74%
, n=1
,203
74%
, n=1
,079
77%
, n=1
,068
79%
, n=1
,301
74%
, n=1
,151
74%
, n=1
,214
80%
, n=1
,242
81%
, n=1
,349
78%
, n=1
,174
84%
, n=1
,104
86%
, n=1
,079
84%
, n=9
86
79%
, n=9
88
80%
, n=9
95
81%
, n=8
90
85%
, n=9
97
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percent Target
Page A23
Performance Measurement Summary
Action Plan
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Non-admitted low acuity patients treated within their respective targets of <=4 hours - Birchmount CampusStrategic Direction Our PatientsTime Frame March 2011Source NACRS
DefinitionPercent of non-admit CTAS 4 and 5 patients treated within 4 hours, measured from registration to leaving Birchmount Campus Emergency Department.
CHART PLACEHOLDER
SignificanceThis is to meet Pay-for-Results expectations. There could be funding impact if targets are not met.
TargetCELHIN Target - 77%, higher value is desired.
Risk RatingN/A
Analysis
Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a
Significant progress has been made through ED PIP and the re-design of the Rapid Assessment Zone (RAZ) leading to consistently meeting or exceeding target.
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Strategic Direction Our Patients
Source
Analysis
May-11
Time Frame Q4 2010/11
Indicator QIP - 90th Percentile ER Lengh of Stay for Admitted Patients
Current StatusMobile Admission Team (MAT) to be implemented June 2011 N.Veloso, A.MacKinnon Funding approved by CELHIN April 2011; post position
by May 2011 with interview and hire June 2011
Date Initiated
Significance90th percentile LOS is suggested indicator Ministry of Health uses to evaluate hospital as part of Excellent Care For All Act (ECFAA).
TargetMOHLTC Target - 25:00, lower value is desired.
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
NACRS
Risk RatingHigh - There will be reputational impact of dissatisfied patients waiting in Emergency Department.
Definition90th percentile ER length of stay for admitted patients, measured from registration to leaving Emergency Department.
CHART PLACEHOLDER
QIP use percentile for Q3 2010/11. 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.
MAT ensure available bed ready (ABR) to in-patient unit transfer time of 45 minutes MAT Not meeting target currently, as MAT develops will review processes and targets
Jun-11
Implementing role change for Crisis Team – from consultant to patient flow coordinator
Patient Flow and Access Steering Committee implemented by June 30, 2011 A.MacKinnon Developing terms of reference by June 2011; site visit to Sunnybrook May 2011; hire manager of patient flow and access June 2011
Admitted Mental Health patients to in-patient bed within 8 hours by September 2011 S.Engels, A.MacKinnon
Collect and analyze data for specialist consultant time to ED by April 1, 2011 A.MacKinnon, N.Mills Break down consultant time data to request date/time and arrival date/time by May 2011; complete root cause analysis on May data in June 2011
Apr-11
Apr-11
Apr-11
32:4
5, n
=4,3
95
29:2
5, n
=3,9
41
36:4
3, n
=4,6
57
44:1
4, n
=6,1
74
0:00
4:00
8:00
12:00
16:00
20:00
24:00
28:00
32:00
36:00
40:00
44:00
48:00
52:00
56:00
60:00
64:00
68:00
Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11
TSH 90th Percentile Target QIP Reported Value=36:43 TSH Median TSH Average
Page A27
Performance Measurement Summary
Action Plan
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator QIP - 90th Percentile ER Length of Stay for Complex Condition Patients
QIP use 90th percentile value for Q3 2010/11. 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.
NACRS
Risk Ratingn/a
Definition90th percentile ER length of stay for non-admitted patients with triage levels 1 to 3, measured from registration to leaving Emergency Department.
CHART PLACEHOLDER
Source
Strategic Direction Our PatientsTime Frame Q4 2010/11
TargetMOHLTC Target - 8:00, lower value is desired.
Apr-11
Apr-11
Apr-11Patient Flow and Access Steering Committee implemented by June 30, 2011 A.MacKinnon
Significance90th percentile LOS is suggested indicator Ministry of Health uses to evaluate hospital as part of Excellent Care For All Act (ECFAA).
Analysis
Jun-11
May-11Date InitiatedSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current Status
Mobile Admission Team (MAT) to be implemented June 2011 N.Veloso, A.MacKinnon Funding approved by CELHIN April 2011; post position by May 2011 with interview and hire June 2011
Developing terms of reference by June 2011; site visit to Sunnybrook May 2011; hire manager of patient flow and access June 2011
Collect and analyze data for specialist consultant time to ED by April 1, 2011 A.MacKinnon, N.Mills Break down consultant time data to request date/time and arrival date/time by May 2011; complete root cause analysis on May data in June 2011
MAT ensure available bed ready (ABR) to in-patient unit transfer time of 45 minutes MAT Not meeting target currently, as MAT develops will Admitted Mental Health patients to in-patient bed within 8 hours by September 2011 S.Engels,
A.MacKinnonImplementing role change for Crisis Team – from consultant to patient flow coordinator
8:51
, n=1
2,32
2
8:17
, n=1
3,35
7
8:19
, n=1
4,17
1
8:01
, n=1
4,40
1
0:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11
TSH 90th Percentile Target QIP Reported Value=8:19 TSH Median TSH Average
Page A28
Performance Measurement Summary
Action Plan
Source
CHART PLACEHOLDER
SignificanceA measure of access and efficiency for patients requiring these procedures.
TargetMOHLTC Target - 182, lower value is desired.
Risk Ratingn/a
General Surgery is performing well against Ontario average and provincial target. Patients are seen in a timely manner.
Analysis
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.
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Wait Time - General Surgery
Time Frame Q4 2010Strategic Direction Our Patients
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/an/a
Date Initiated
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
76, n
=534
-
20
40
60
80
100
120
140
160
180
200
TSH 90th Percentile Ontario Target TSH Median TSH Average
Page A29
Performance Measurement Summary
Action Plan
Source
Date Initiatedn/a
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
AnalysisCancer Surgery is performing well against Ontario average and provincial target. Patients are seen in a timely manner.
MOHLTC Wait Times Website / CCO Iport
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Wait Time - Cancer Surgery Strategic Direction Our PatientsTime Frame Q4 2010
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a
43, n
=100
46, n
=159 60
, n=2
17
53, n
=234
50, n
=169
59, n
=192 74
, n=2
23
49, n
=221
57, n
=191
54, n
=173
53, n
=220
-
10
20
30
40
50
60
70
80
90
100
TSH 90th Percentile Ontario Target TSH Median TSH Average
Page A30
Performance Measurement Summary
Action Plan
n/a
SignificanceA measure of access and efficiency for patients requiring these procedures.
TargetMOHLTC Target - 182, lower value is desired.
Risk RatingLow - Due to the lack of funding, TSH may not meet Ontario wait time target for cataracts. This may have a reputational, financial and operational risk to the program; however, TSH is meeting or exceeding wait times in all other areas.
AnalysisThe wait time for cataract surgery has increased between April to December 2010 above the provincial target. This 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 positively impacted Q4's wait time.
Date InitiatedSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Wait Time - Cataract SurgeryStrategic Direction Our Patients
Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a
Q4 2010Source MOHLTC Wait Times Website / CCO IportTime Frame
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
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
225,
n=1
310
120,
n=2
035
-
50
100
150
200
250
300
TSH 90th Percentile Ontario Target TSH Median TSH Average
Page A31
Performance Measurement Summary
Action Plan
Source
Date Initiatedn/a
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
AnalysisTotal Hip Replacement Surgery is performing well against Ontario average and provincial target. Patients are seen in a timely manner.
MOHLTC Wait Times Website / CCO Iport
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Wait Time - Total Hip ReplacementStrategic Direction Our PatientsTime Frame Q4 2010
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a
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
131,
n=6
5
-
50
100
150
200
250
TSH 90th Percentile Ontario Target TSH Median TSH Average
Page A32
Performance Measurement Summary
Action Plan
Source
Date Initiatedn/a
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
AnalysisTotal Knee Replacement Surgery is performing well against Ontario average and provincial target. Patients are seen in a timely manner.
MOHLTC Wait Times Website / CCO Iport
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Wait Time - Total Knee ReplacementStrategic Direction Our PatientsTime Frame Q4 2010
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a
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
108,
n=2
30
-
50
100
150
200
250
TSH 90th Percentile Ontario Target TSH Median TSH Average
Page A33
Performance Measurement Summary
Action Plan
n/a
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
AnalysisReduction 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.
Date InitiatedSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Wait Time - CTStrategic Direction Our Patients
Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a
Q4 2010Source MOHLTC Wait Times Website / CCO IportTime Frame
DefinitionWait time is defined as the 90th percentile number of days wait for CT diagnostic scan.
CHART PLACEHOLDER
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
19, n
=543
5
-
10
20
30
40
50
TSH 90th Percentile Ontario Target TSH Median TSH Average
Page A34
Performance Measurement Summary
Action PlanSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
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
AnalysisMOHLTC target for priority 4 cases is 28 days and the CELHIN has a target of 65 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.
Current Status
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Wait Time - MRIStrategic Direction Our Patients
Increase TSH MRI service by 2080 hrs/yr with 2nd MRI unit, slated for opening September 2011 at the Birchmount Campus. RFP issued/responses received/evaluation completed.Contract award projected June 2011
T.Jackson Currently in progress
Q4 2010Source MOHLTC Wait Times Website / CCO IportTime Frame
Dec-10
DefinitionWait time is defined as the 90th percentile number of days wait for MRI diagnostic scan.
Date Initiated
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
97, n
=294
1
-
20
40
60
80
100
120
140
160
180
TSH 90th Percentile Ontario Target TSH Median TSH Average
Page A35
Performance Measurement Summary
Action Plan
SignificanceThis indicator is a measure of patient's overall impression of the quality of care received.
TargetTSH target is 50 for ED, higher value is desired. The target is based on GTA average.
Date InitiatedSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current Status
Analysis
CHART PLACEHOLDER
QIP use average for most recent 12 month period (November 2009 to October 2010). TSH Emergency Department satisfaction scores is above the target. TSH has made positive changes such as Code of Conduct, and faster response time to patient complaint by Patient Relations department.
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator QIP - Patient satisfaction - Overall Impression: Emergency Department
n/aIndicator meeting or exceeding target, no action plan required n/a n/a
Risk Ratingn/a
Strategic Direction Our Patients
Source NRC Picker
DefinitionResponse to Overall Impression questions in NRC Picker survey administered to a sample of discharged Emergency Department patients:- Emergency Department (ED): Would you recommend TSH for Emergency Department services?
Time Frame Q4 2010/11 (Jan)
41.5
n=1
35
46.8
n=1
54
48.3
n=1
43
44.3
n=2
12
49.5
n=1
94
46.7
n=1
95
54.5
n=2
2
0
20
40
60
80
100
ED Score Target - GTA ED Avg QIP ED Value Reported=60.4
Page A36
Performance Measurement Summary
Action Plan
Hospitalist Program: The implementation of the hospitalist program on 2 inpatient units at the General campus will improve patient satisfaction on dimensions related to physician availability and communication to meet and surpass GTA targets on a quarterly basis
N. Veloso, Dr. Lukowski, Dr. Clasky
Sep-10 Ongoing, Hospitalist scorecard and quarterly performance meetings
GAIN Clinic: The GAIN clinic will promote better outcomes for frail seniors by providing outpatient geriatric assessment and intervention service to meet regional targets on a quarterly basis
D. Driver, N.Veloso Jan-10 Ongoing, GAIN Scorecard and biweekly regional performance monitoring meetings
Senior Friendly Philosophy: All inpatient and outpatient services to implement Senior Friendly best practices and environmental improvements in accordance with RGP (Regional Geriatric Program) guidelines by 2011/12
N. Veloso, T. Bowers Mar-10 Assessment of current status to develop implementation plans
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current Status
SignificanceThis indicator is a measure of patient's overall impression of the quality of care received.
TargetTSH target is 73 for IP, higher value is desired. The target is based on GTA average.
Risk RatingHigh- Reputational, financial or operational risk.
Analysis
Time Frame Q4 2010/11 (Jan)Source NRC Picker
DefinitionResponse to Overall Impression questions in NRC Picker survey administered to a sample of discharged In-patients:- Inpatients: Would you recommend TSH for an In-patient stay?
CHART PLACEHOLDER
QIP use average for most recent 12 month period (November 2009 to October 2010). 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.
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
IP Score Target - GTA IP Avg QIP IP Value Reported=60.4
Page A37
Patient Rounding Practices: The introduction of weekly inpatient rounding practices to promote direct communication with patients and families for quality improvement opportunities will improve patient satisfaction scores related to communication and patient experience to meet GTA targets on a quarterly basis
T. Early, A. Visva Apr-11 Implementation on one inpatient unit - 4D Birchmount. Spread to other inpatient units over 2011/12 and embedded in unit level scorecards
VALUE Program: The introduction of the VALUE (Volunteers Assisting the Leisure Unique needs of the Elderly) on CP1 would promote the stimulation and communication with patients to promote a positive patient experience as indicated by the NRC picker data to meet GTA targets in 2011/12
M. DePaulsen Apr-11 Implementation in progress
Page A38
Performance Measurement Summary
Action Plan
Risk Ratingn/a
CHART PLACEHOLDER
Source Finance
SignificanceTo ensure the Hospital is operating in a balanced or surplus position.
TargetTSH Target - 0%, target value is desired.
AnalysisQIP use percent for Q3 2010/11. Q4 result of 0.04% reflects a surplus for 2010/11.
2010/11
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
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator QIP - Total marginStrategic Direction Our Performance
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a n/a
-2.0%
-1.5%
-1.0%
-0.5%
0.0%
0.5%
1.0%
2006/07 2007/08 2008/09 2009/10 2010/11
Total Margin Target QIP Reported Value=0.27%
Page A39
Performance Measurement Summary
Action Plan
The provincial target for current ratio is 0.8 to 2.0, however, many hospitals including TSH are below this target due to accumulated operating deficits and unfunded capital expenditures.
Time Frame 2010/11 (Apr-Dec)Source Finance
DefinitionCalculated by dividing current assets by current liabilities. A value of less than 1.0 (100%) indicates that the current assets are less than current liabilities. The Hospital Accountability Agreement uses a variation: current assets/current liabiities less deferred contribution and this is the one that is shown below.
CHART PLACEHOLDER
SignificanceTo assess the Hospital's ability to pay its short-term obligations.
TargetTSH Target - 0.39, higher value is desired.
Risk RatingMedium- Reputational, financial or operational risk.
Analysis
Strategic Direction Our Performance
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Current Ratio
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusQuarterly review by Senior Management Team to ensure a current ratio of 0.39 or better is maintained
R. Anstey In progress, on a quarterly basisJul-10Date Initiated
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
2007/08 2008/09 2009/10 2010/11 (Apr-Dec)Current Ratio Target
Page A40
Performance Measurement Summary
Action Plan
We are currently below target.
Time Frame 2010/11 (projected based on Apr-Dec 2010)Source Finance
DefinitionWeighted Cases is the sum of the Resource Intensity Weight (RIW) of each case. Patients with higher weighting are expected to require more resources. This is also seen as a proxy for complexity of cases.
CHART PLACEHOLDER
SignificanceTo track our volumes of weighted cases to ensure that we are meeting our MOHLTC commitments.
TargetMOHLTC Target - 40,712, target value is desired.
Risk Ratingn/a
Analysis
Strategic Direction Our Performance
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Total weighted cases (Inpatient and Day Surgery)
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/an/a
Date Initiated
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
50,000
2007/08 2008/09 2009/10 2010/11 (projected based on Apr-Dec 2010)
Weighted Cases Target
Page A41
Performance Measurement Summary
Action Plan
We are currently above target.
Time Frame 2010/11 (projected based on Apr-Dec 2010)Source Finance
DefinitionActual Mental Health Inpatient Days.
CHART PLACEHOLDER
SignificanceTo track our volumes of mental health inpatient days to ensure that we are meeting our MOHLTC commitments.
TargetMOHLTC Target - 15,000, target value is desired.
Risk Ratingn/a
Analysis
Strategic Direction Our Performance
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Mental Health Patient Days
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/an/a
Date Initiated
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
2007/08 2008/09 2009/10 2010/11 (projected based on Apr-Dec 2010)
Mental Health Patient Days Target
Page A42
Performance Measurement Summary
Action Plan
We are currently below target.
Time Frame 2010/11 (projected based on Apr-Dec 2010)Source Finance
DefinitionActual Rehabilitation Inpatient Days.
CHART PLACEHOLDER
SignificanceTo track our volumes of rehabiliation inpatient days to ensure that we are meeting our MOH commitments.
TargetMOHLTC Target - 3,530, target value is desired.
Risk RatingMedium- Reputational, financial or operational risk.
Analysis
Strategic Direction Our Performance
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Rehab Patient Days
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusNegotiated with LHIN to reduce target for 2011/12 that reflects current practices A. Ralph CompletedMar-11
Date Initiated
0
1,000
2,000
3,000
4,000
5,000
6,000
2007/08 2008/09 2009/10 2010/11 (projected based on Apr-Dec 2010)
Rehab Patient Days Target
Page A43
Performance Measurement Summary
Action Plan
We are currently above target. Over the last few years, most of of the growth was at the Birchmount Campus.
Time Frame 2010/11 (projected based on Apr-Dec 2010)Source Finance
DefinitionTotal Emergency Department (ED) visits reports the volume of patients who are registered in the ED and is indicative of the demand on the ED frm the community.
CHART PLACEHOLDER
SignificanceTo track ED visits to measure against our MOHLTC commitment
TargetMOHLTC Target - 98,000, target value is desired.
Risk Ratingn/a
Analysis
Strategic Direction Our Performance
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Emergency Visits
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/an/a
Date Initiated
0
20,000
40,000
60,000
80,000
100,000
120,000
2007/08 2008/09 2009/10 2010/11 (projected based on Apr-Dec 2010)
ED Visits Target
Page A44
Performance Measurement Summary
Action Plan
We are currently above target.
Time Frame 2010/11 (projected based on Apr-Dec 2010)Source Finance
DefinitionTotal ambulatory visits registered in Meditech, excluding Emergency Department.
CHART PLACEHOLDER
SignificanceTo track Ambulatory visits to measure against our MOHLTC commitment
TargetMOHLTC Target - 294,773, target value is desired.
Risk Ratingn/a
Analysis
Strategic Direction Our Performance
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Ambulatory Visits (excluding ER)
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/an/a
Date Initiated
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
2007/08 2008/09 2009/10 2010/11 (projected based on Apr-Dec 2010)
Total Ambulatory (excl ED) Target
Page A45
Performance Measurement Summary
Action Plan
We are currently above target.
Time Frame 2010/11 (projected based on Apr-Dec 2010)Source Finance
DefinitionTotal hip joint replacement and knee replacement.
CHART PLACEHOLDER
SignificanceTo track volume to measure against our MOHLTC commitment
TargetMOHLTC Target - 1,225, target value is desired.
Risk Rating
Analysis
Strategic Direction Our Performance
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Total Hip and Knee Replacement
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/an/a
Date Initiated
0
200
400
600
800
1,000
1,200
1,400
1,600
2007/08 2008/09 2009/10 2010/11 (projected based on Apr-Dec 2010)
Total Hip and Knee Target
Page A46
Performance Measurement Summary
Action Plan
We are currently below target. Figures based on Q3 data. Next data update will be in June 2011. In Q4 the CE LHIN allocated additional 400 cataracts to assist TSH. The additional cataract volumes have positively impacted Q4's wait time. It is expected that the total cataract surgeries will increase for Q4.
Time Frame 2010/11 (projected based on Apr-Dec 2010)Source Finance
DefinitionTotal Cataract Surgeries.
CHART PLACEHOLDER
SignificanceTo track volume to measure against our MOHLTC commitment.
TargetMOHLTC Target - 5,815, target value is desired.
Risk RatingMedium- Reputational, financial or operational risk.
Allocated wait time blocks to Optomology surgeons with the highest wait time and longest wait list to reduce wait time to line with CELHIN target by Q4
PDS, Surgery
Analysis
Strategic Direction Our Performance
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Cataract Surgeries
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusContinue to monitor the performance of surgeons, wait time and OR blocks utilization monthly
N. Rahim Ongoing monthlyDec-10Date Initiated
Jan-11 Completed as of March 31, 2011
Wait time data clean-up process to start in January 2011 for all optomology surgeons by Q4Request additional funding from the CE LHIN to help reduce the wait list by Q4
PDS, Surgery Jan-11 Completed as of March 31, 2011
PDS, Surgery Jan-11 Completed as of March 31, 2011
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
2007/08 2008/09 2009/10 2010/11 (projected based on Apr-Dec 2010)
Cataract Target
Page A47
Performance Measurement Summary
Action Plan
We are currently above target.
Time Frame 2010/11 (projected based on Apr-Dec 2010)Source Finance
DefinitionTotal Computed Tomography (CT) hours.
CHART PLACEHOLDER
SignificanceTo track volume to measure against our MOHLTC commitment.
TargetMOHLTC Target - 7,245, target value is desired.
Risk Ratingn/a
Analysis
Strategic Direction Our Performance
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Computed Tomography (CT)
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/an/a
Date Initiated
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
2007/08 2008/09 2009/10 2010/11 (projected based on Apr-Dec 2010)
CT Hours Target
Page A48
Performance Measurement Summary
Action Plan
We are currently above target.
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
Time Frame 2010/11 (projected based on Apr-Dec 2010)Source Finance
DefinitionTotal Magnetic Resonance Imaging (MRI) hours.
CHART PLACEHOLDER
SignificanceTo track volume to measure against our MOHLTC commitment.
TargetMOHLTC Target - 5.657, target value is desired.
Risk Ratingn/a
Analysis
Strategic Direction Our Performance
The Scarborough HospitalCorporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Magnetic Resonance Imaging (MRI)
Current StatusIndicator meeting or exceeding target, no action plan required n/a n/an/a
Date Initiated
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
2007/08 2008/09 2009/10 2010/11 (projected based on Apr-Dec 2010)
MRI Hours Target
Page 2
Performance Measurement Summary
Action Plan
• TSH patients continue to receive timely access to care. TSH wait time for general surgery, cataract surgery, hip/knee, CT is below the provincial average.• The wait time for MRI is above the Ontario average, however, the wait time has decreased to 97 in Q4 2010/11.• The wait time for cataract surgery has decreased in Q4 2010/11 below the provincial target. 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 positively impacted Q4's wait time.
SourceQ4 2010/11
Strategic Direction
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 increase in the number of CLI cases at the General campus. Overall, TSH is above the Ontario average. Standardization of CLI strategies across the campuses will assist in decreasing CLI cases across TSH.• There has been zero VAP cases identified at the General campus and Birchmount campus in the last quarter. Both campuses are below the Ontario average.• SSI - Antibiotics Timing - Hip/Knee: Work continues on ensuring a good process for improvement on this indicator.
DefinitionPercentage of 16 publicly reported patient safety indicators that meet the provincial targets.
Meditech, NACRS, IPAC, MOHLTC Wait Times Public Website
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
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Percentage of publicly reported patient safety indicators meeting the provincial target (see addendum)
Time FrameOur Patients
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current StatusMobile Admission Team (MAT) to be implemented June 2011 N.Veloso, A.MacKinnon May-11 Funding approved by CELHIN April 2011; post position
by May 2011 with interview and hire June 2011
MAT ensure available bed ready (ABR) to in-patient unit transfer time of 45 minutes MAT Jun-11 Not meeting target currently, as MAT develops will review processes and targets
Admitted Mental Health patients to in-patient bed within 8 hours by September 2011 S.Engels, A.MacKinnon
Apr-11 Implementing role change for Crisis Team – from consultant to patient flow coordinator
Patient Flow and Access Steering Committee implemented by June 30, 2011 A.MacKinnon Apr-11 Developing terms of reference by June 2011; site visit to Sunnybrook May 2011; hire manager of patient flow and access June 2011
Apr-11 Break down consultant time data to request date/time and arrival date/time by May 2011; complete root cause analysis on May data in June 2011
RAZ dedicated physician shift to be implemented in October 2011 Dr. T.Chan May-11 Currently recruiting, interviewing and preparing for appointment for October 2011
Collect and analyze data for specialist consultant time to ED by April 1, 2011 A.MacKinnon, N.Mills
Apr-10 Monthly audits
Expanded data collection to investigate higher rate of CLI in the hemodialysis population by Q2 of 2011/12
H. Clasky, R. Lovinsky, IPAC
All Rapid Assessment Zone (RAZ) patients will have an ALOS of 3.5 hours at the Birchmount Campus and 4.0 hours at the General Campus by September 2011
D.Edman, T.Reardon, N.Alli
Apr-11 1. Implemented an elite RAZ team April 20112. Hours of operation changed from 12 hours to 24 hours May 2011
Mar-11 Data collection in progress
Through the implementation of a Geriatric Mental Health program, the ED LOS of elders with delirium, dementia and depression will be < 8 hours by December 2011
E.Laine, S.Vellani May-11 1. Program approved by CE LHIN April 20112. Implementation team struck May 2011
Increase TSH MRI service by 2080 hrs/yr with 2nd MRI unit, slated for opening September 2011 at the Birchmount Campus. RFP issued/responses received/evaluation completed.Contract award projected June 2011
T.Jackson Dec-10 Currently in progress
Ongoing monthly monitoring of insertion and maintenance Bundle with compliance of 90%
H. Clasky, D. Rose, P. Tamlin, R. Lovinsky, C.
Page 4
Performance Measurement Summary
Action Plan
Time FrameSource
n/aDate InitiatedSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
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)
Strategic DirectionQ4 2010/11
Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a
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
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.
403
467
576
521
626
705 73
0 768
0
100
200
300
400
500
600
700
800
900
Q1 Q2 Q3 Q4
2009/10 2010/11 Target
Page 5
Performance Measurement Summary
Action Plan
We are currently meeting our target for this fiscal year.
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a n/a
Time Frame 2010/11Source Internal Tracking
DefinitionThe number of staff and physicians who have been trained in programs that advance our Mission, Vision and Values defined behaviours.
CHART PLACEHOLDER
SignificanceTo improve patient care and quality of service. To support alignment of staff and physicians with hospital strategies.
TargetInternal Target - 75%, higher value is desired.
Risk Ratingn/a
Analysis
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Percentage of staff and physicians trained in Mission, Vision and Values defined behavioursStrategic Direction Our People
79%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
2010/11
% of Staff and Physicians trained Target
Page 6
Performance Measurement Summary
Action Plan
SignificanceTo track trends in employee satisfaction in order to identify and implement necessary improvement plans.
AnalysisAll 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.
TargetOntario Average - 59% for 2010/11 and 55% for 2008/09, higher value is desired.
Risk Ratingn/a
Date InitiatedC. Hill
2010/11Time FrameSource NRC Picker
CHART PLACEHOLDER
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
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.
Scheduled for Fall 2011Current Status
Fall 2011Introduce Pulse Survey to measure engagement on a quarterly basis by Q3 2011/12
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%
70%
2008/09 2010/11
Commitment Score Target
Page 7
Performance Measurement Summary
Action Plan
The Scarborough HospitalCorporate Balanced Scorecard
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
Time FrameOur PeopleStrategic Direction
Apr-11
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
Apr-11Date Initiated
Source NRC Picker
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusUpdate performance appraisals by aligning with code of conduct and implement 25% by Q4 2011/12
Dr. S. Jackson In progress, updating performance review
Development of robust communication plan with family physicians by Q4 2011/12 Dr. S. Jackson In progress, planning initiated
The development of Physician leadership award by Q3 2011/12 Dr. S. Jackson In progress, planning initiatedApr-11
28.8
%, n
=141
42.7
%, n
=151
0%
10%
20%
30%
40%
50%
60%
2008/09 2010/11
Commitment Score Target
Page 8
Performance Measurement Summary
Action Plan
SignificanceModel of Care positions supports excellent care and full scope of practice and enhances partnerships between practice and operations.
TargetInternal Target - 100%, higher value is desired.
Risk Ratingn/a
AnalysisAll positions have been transitioned and all are functioning in the role.
n/aDate InitiatedSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Percentage of defined Model of Care positions transitioned
Source Internal Tracking
Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a
Strategic Direction Our PeopleTime Frame 2010/11
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
100%
, n=2
1
0%
20%
40%
60%
80%
100%
120%
140%
2010/11
% positions transitioned Target
Page 9
Performance Measurement Summary
Action PlanCurrent Status
Developing a strategy to improve the particiaption in performance discussions by Q1 2011/12
C.Hill In progressDate InitiatedMay-11
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
2010/11Source MediHR
DefinitionPercentage of leaders with completed annual performance evaluations. Percentage based on total number of non-union management positions in the hospital.
CHART PLACEHOLDER
TargetInternal Target - 50%, higher value is desired.
Risk Ratingn/a
Analysis
The Scarborough HospitalCorporate Balanced Scorecard
We are currently below target for this fiscal year. Further discussion is required to identify learning gaps.
Indicator Percentage of leaders with completed performance evaluationsStrategic Direction Our People
SignificanceEmployee evaluation is important for leaders to be aware of development needs.
Time Frame
21%
0%
10%
20%
30%
40%
50%
60%
2010/11
% Leaders with completed evaluation Target
Page 10
Performance Measurement Summary
Action Plan
n/aSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead
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 completed for the fiscal year.
Date Initiated
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Percentage of Medical Directors with completed performance evaluations
Source Internal Tracking
Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a
Strategic Direction Our PeopleTime Frame Q4 2010/11
DefinitionPercentage of Medical Directors with completed annual performance evaluations. Percentage based on total number of Medical Directors in the hospital.
CHART PLACEHOLDER
80%
, n=8
100%
, n=1
0
0%
20%
40%
60%
80%
100%
120%
140%
Q3 2010/11 Q4 2010/11
% Medical Directors with completed evaluation Target
Page 11
Performance Measurement Summary
Action Plan
We are currently below target for this fiscal year. Further discussion is required to identify learning gaps.
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current StatusDeveloping a strategy to improve the particiaption in performance discussions by Q1 2011/12
C.Hill May-11 In progress
Time Frame 2010/11Source MediHR
DefinitionPercentage of non-unionized staff with completed annual performance evaluations. Percentage based on total number of non-union positions in the hospital.
CHART PLACEHOLDER
SignificanceEmployee evaluation is important for development of staff and managers to be aware of employee development needs.
TargetInternal Target - 50%, higher value is desired.
Risk Ratingn/a
Analysis
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Percentage of non-unionized staff with completed performance evaluationsStrategic Direction Our People
46%
0%
10%
20%
30%
40%
50%
60%
2010/11
% Non-unionized with completed evaluation Target
Page 12
Performance Measurement Summary
Action Plan
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Percentage of unionized staff with completed performance evaluationsStrategic Direction Our PeopleTime Frame 2010/11Source MediHR
DefinitionPercentage of unionized staff with completed annual performance evaluations. Percentage based on total number of union positions in the hospital.
CHART PLACEHOLDER
SignificanceEmployee evaluation is important for development of staff and managers to be aware of employee development needs.
TargetInternal Target - 30%, higher value is desired.
Risk Ratingn/a
AnalysisWe are currently below target for this fiscal year. Further discussion is required to identify learning gaps.
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current StatusDeveloping a strategy to improve the particiaption in performance discussions by Q1 2011/12
C.Hill May-11 In progress
6%
0%
5%
10%
15%
20%
25%
30%
35%
2010/11
% Unionized with completed evaluation Target
Page 13
Performance Measurement Summary
Action Plan
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Percentage of leaders educated in LEAN methodologyStrategic Direction Our PeopleTime Frame 2010/11Source Internal Tracking
DefinitionPercentage of leaders (i.e. clinical resource leaders, managers, directors, VP's) who have received education in LEAN methodology.
CHART PLACEHOLDER
SignificanceLEAN is the management philosophy that TSH is implementing over the next year. In order to successfully lead the clinical teams it is necessary that 100% of organizational Leaders be trained in LEAN methods.
TargetInternal Target - 100%, higher value is desired.
Risk Ratingn/a
AnalysisCurrently, 17% of leaders are trained in LEAN methodology. There is a training plan for the next 3-6 months that will ensure that TSH reaches it's target of 100%.
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current StatusImplement LEAN training plan for leaders. Complete LEAN training by December 2011
TBD Apr-11 In progress, an RFP will be issued within the next fiscal quarter to select the vendor who will complete this training
17%
, n=9
0
0%
20%
40%
60%
80%
100%
120%
2010/11
% Leaders educated in LEAN Target
Page 14
Performance Measurement Summary
Action PlanSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current Status
Feb-11Date Initiated
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
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
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
Expedite acquisition of major pieces of equipment included in 2011/12 Capital Plan by Q4
R. Anstey There is a delay in acquisition of new equipment (i.e. CTs)
HIT indicator #17, Percentage of equipment cost to total expenseOur Programs, Plans and Partners
The Scarborough HospitalCorporate Balanced Scorecard
Majority of missed Q4 milestones were Business Case presentations to leadership, which was scheduled on project plans to occur in February. The meeting occurred on March 7, with six Business Case presentations and three selected to move forward.
CHART PLACEHOLDER
SignificanceA measure of department performance, efficiency and planning.
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current Status
Our Programs, Plans, and PartnersQ4 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.
TargetInternal Target - 80%, higher value is desired.
Risk RatingLow - Impact would be operational (i.e. quality).
J. Cox Ongoing, part of PMO normal operational accountability
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Percentage of PMO project milestones metStrategic DirectionTime FrameSource
PMO developing categorization of reasons for missing milestones in order to identify root cause
J. Cox In progress, proposed categorization will be presented to and approved by PMO Advisory Committee in June 2011
Apr-11Oct-10
Inventory of task timelines being development to guide future project plans (e.g. RFP development and positing, contract negotiation, hardware procurement)
J. Cox In progress, as project tasks are completed- time to complete these tasks are added to the inventory. These average times are used for new project schedules
Oct-10
PMO Lead reviewing all project milestones to ensure they meet the milestone
94%
, n=1
5
96%
, n=2
2
47%
, n=2
0
40%
, n=2
1
0%
20%
40%
60%
80%
100%
120%
Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11
% milestones achieved Target
Page 16
Performance Measurement Summary
Action PlanSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current Status
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.
Q4 2010/11Time FrameSource
Analysis
Strategic Direction Our Performance
CHART PLACEHOLDER
TargetInternal Target - 100%, higher value is desired.
Risk RatingLow - Impact would be operational (i.e. quality).
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.).
Performance & Decision Support
SignificanceRoutine uploading of scorecards will facilitate regular review of the indicators and transparency to the staff and other departments.
VP/ED Scorecards to be sent to PDS upon completion for publication on the PDS SharePoint site on a quarterly basis
C. Flemming Aug-10 Pending
85%
, n=1
7
75%
, n=1
5
75%
, n=1
5
65%
, n=1
3
0%
20%
40%
60%
80%
100%
120%
Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11
% of posted scorecards Target
Page 17
Performance Measurement Summary
Action Plan
DefinitionOverall percent achievement of 8 accountability agreement indicators: (Total Margin, Current Ratio, Weighted Cases, MH Patient Days, Rehab Patient Days, ER Visits, Amb Visits).
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.
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.
The Scarborough HospitalCorporate Balanced Scorecard
Indicator Percentage of accountability agreement indicators achieved
Time FrameStrategic Direction
Q3 2010/11
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current StatusIndicator meeting or exceeding target, no action plan required n/a n/an/a