Tsh scorecard   corporate - 2010 11 q3 b
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    Tsh scorecard   corporate - 2010 11 q3 b Tsh scorecard corporate - 2010 11 q3 b Presentation Transcript

    • The Scarborough Hospital Corporate Balanced Scorecard Q3 2010/11 Our 1st Priority 1st Qtr Current Previous Current RiskStrategic Direction (to 30-Jun-11) Indicator Reported Value Value Target Status Rating* Page Our Patients: Patient satisfaction - Overall Impression: Create an environment of patient safety that ● ED: Would you recommend TSH for Emergency Department services? 49.1 49.7 50 R H 2 exceeds our patients highest expectations and delivers care that is patient and family ● IP: Would you recommend TSH for an In-patient stay? 67.2 61.9 73 Y n/a 2 driven. Percentage of publicly reported patient safety indicators meeting the provincial target (see addendum) 63% 58% 100% Y n/a 4 Number of incident reports completed (medication and non-medication) 743 730 490 G n/a 6 Hospital Standardized Mortality Ratio (HSMR) 74 84 100 G n/a 7 Service Rate of hand hygiene compliance before initial patient/patient environment contact 85% 92% 90% R 8 Excellence: To Rate of hand hygiene compliance after patient/patient environment contact 89% 96% 90% R 8 Our People: provide respectful Percentage of staff and physicians educated in Mission, Vision and Values defined behaviours Q4 Be the first choice for motivated, talented and responsive Staff and Physician satisfaction: people who are inspired to deliver and support excellent care in a diverse service to our ● Employee Satisfaction survey results (Commitment composite score) 50.9% 37.5% 59% Y n/a 9 environment. patients and each ● Physician Satisfaction survey results (Commitment composite score) 42.7% 28.8% 43% Y n/a 10 other. Percentage of defined Model of Care positions transitioned 100% 100% G n/a 11 Performance evaluations ● Percentage of leaders with completed performance evaluations Q3 100% ● Percentage of Medical Directors with completed performance evaluations Q3 80% 100% Y n/a 12 ● Percentage of non-union staff with completed performance evaluations Q3 100% ● Percentage of unionized staff with completed performance evaluations Q3 50% Percentage of leaders educated in LEAN methodology Q4 Our Programs, Plans and HIT indicator #17, Percentage of equipment cost to total expense 5.2% 5.4% 5.9% R M 13 Partners: Q1 As a unified organization, lead the Number of standardized order sets used 2011/12 development of a coordinated plan for the provision of care for all of Scarborough. Percentage of Clinical Service Plan (CSP) recommendations implemented Q4 100% Our Performance: Percentage of PMO project milestones met 47% 96% 80% R M 14 Create an accountable, high performing Percentage of Programs and Departments with performance indicator scorecards and action plans organization that delivers measureable 75% 75% 100% Y n/a 15 results. that are posted and updated quarterly on the Intranet Total margin 0.30% -0.31% 0% G n/a 16 Percentage of accountability agreement indicators achieved 88% 88% 80% G n/a 17* Risk rating only completed for indicators that are not meeting the target and have not improved over the prior reporting periodCurrent Status Legend: Risk Rating LegendRed = Performance indicator has not met the target for the current reporting period, and has not improved over the prior reporting period L = Low reputational, financial or operational riskYellow = Performance is below the target, however it has improved over the previous reporting period M = Medium reputational, financial or operational riskGreen = Performance indicator has met or exceeded or is not statistically different than the performance target for the current reporting period H = High reputational, financial or operational risk Vision: To be recognized as Canada’s leader in providing the best healthcare for a global community. Mission: To provide an outstanding care experience that meets the unique needs of each and every patient. Values: I ntegrity, C ompassion, A ccountability, R espect, E xcellence Page 1
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety Indicators Current Previous CurrentStrategic Direction Indicator Value Value Target Status Risk Rating* Page Our Patients: Emergency Department Wait Time for High Acuity Visits - General Campus 19:35 15:12 8:00 R H A1 Create an environment of Emergency Department Wait Time for High Acuity Visits - Birchmount Campus 22:51 12:12 8:00 R H A2 Emergency Department Wait Time for Low Acuity Visits - General Campus 5:31 4:48 4:00 R H A3 Emergency Department Wait Time for Low Acuity Visits - Birchmount Campus 4:57 4:30 4:00 R H A4 Percent of CTAS 1&2 meeting 8 hour target 66% 71% 90% R H A5 Percent of CTAS 3 meeting 6 hour target 66% 73% 90% R H A6 Percent of CTAS 4&5 meeting 4 hour target 79% 84% 90% R H A7 Rate of Hospital Acquired C. difficile Associated Diarrhea 0.32 0.22 0.28 R M A8 Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia 0.00 0.00 0.02 G n/a A9 Rate of Hospital Acquired Vancomycin Resistant Enterococcus (VRE) Bacteraemia 0.00 0.00 0.00 G n/a A10 Rate of Central Line Infection (CLI) 1.48 0.61 0.75 R A11 Rate of Ventilator Associated Pneumonia (VAP) 0.00 0.76 1.46 G n/a A12 Rate of Timely Administration of Prophylactic Antibiotics - Primary Hip & Knee 98.0% 97.6% 96.1% G n/a A13 Wait Time - General Surgery 82 67 182 G n/a A14 Wait Time - Cancer Surgery 65 54 84 G n/a A15 Wait Time - Cataract Surgery 123 223 182 G n/a A16 Wait Time - Total Hip Replacement 123 151 182 G n/a A17 Wait time - Total Knee Replacement 106 153 182 G n/a A18 Wait Time - CT 20 23 28 G n/a A19 Wait Time - MRI 99 116 28 Y M A20* Risk rating only completed for indicators that are not meeting the target and have not improved over the prior reporting periodStatus Legend: Risk Rating LegendRed = Performance indicator has not met the target for the current reporting period, and has not improved over the prior reporting period L = Low reputational, financial or operational riskYellow = Performance is below the target, however it has improved over the previous reporting period M = Medium reputational, financial or operational riskGreen = Performance indicator has met or exceeded or is not statistically different than the performance target for the current reporting period H = High reputational, financial or operational risk Vision: To be recognized as Canada’s leader in providing the best healthcare for a global community. Mission: To provide an outstanding care experience that meets the unique needs of each and every patient. Values: I ntegrity, C ompassion, A ccountability, R espect, E xcellence Page Addendum
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Emergency Department Wait Time for High Acuity Visits - General CampusStrategic Direction Our PatientsTime Frame Q4 2010/11 (Jan)Source MOHLTC Wait Times Website / NACRSPerformance Measurement SummaryDefinition 19:35, n=3518 16:47, n=8517This indicator reports the 90th Percentile Wait time for all ED Admits with CTAS 1-5 22:00 15:54, n=8051 15:48, n=8883 15:12, n=10727 15:32, n=8512 15:31, n=7938and NonAdmits with CTAS 1-3. 20:00 13:12, n=9747 18:00Significance 16:00This indicator is associated with efficiency within the ED and within the hospital, aswell as with ED patient satisfaction. 14:00 12:00Target 10:00MOHLTC Target - 8:00, lower value is desired. 8:00 CHART PLACEHOLDERRisk Rating 6:00High - There will be reputational impact of dissatisfied patients waiting in Emergency 4:00Department and potential financial risk of losing Pay-for-Results funding.Analysis 2:00There are challenges related to discharge processes, bed turnover times, and bed 0:00availability. As a result of ED PIP, white boards, discharge huddles, patienteducation and discharge processes have improved on participating units. Spreadingthe concept to other units is underway. Changing the philosophy to sharedaccountability for patients is spreading. General Campus TargetAction PlanInitiative Lead Date Initiated StatusED PIP initiated J. Phan Sep-09 OngoingGEM D. Driver Oct-09 OngoingCharge Nurse and Triage RN Education T. Reardon Mar-10 OngoingVirtual CDU implemented Dr T. Chan Apr-10 OngoingSchedule to Demand D. Edman Jun-10 CompletedRounding for Outcomes D. Edman Jun-10 OngoingPerformance Huddles Leadership Team Jun-10 OngoingNP LTC B. Bickle Jun-10 OngoingED PIP Kaizen Events S. Gilbert Aug-10 In progressSchedule to Demand M. Tang Jan-11 Pending Page A1
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Emergency Department Wait Time for High Acuity Visits - Birchmount CampusStrategic Direction Our PatientsTime Frame Q4 2010/11 (Jan)Source MOHLTC Wait Times Website / NACRSPerformance Measurement SummaryDefinition 22:51, n=2519This indicator reports the 90th Percentile Wait time for all ED Admits with CTAS 1-5 2:00and NonAdmits with CTAS 1-3. 0:00 17:02, n=6387 16:45, n=6561 16:31, n=6673 22:00 15:30, n=6325 14:06, n=6668 13:36, n=6812 20:00Significance 12:12, n=7166This indicator is associated with efficiency within the ED and within the hospital, as 18:00well as with ED patient satisfaction. 16:00 14:00Target 12:00MOHLTC Target - 8:00, lower value is desired. 10:00 CHART PLACEHOLDER 8:00Risk RatingHigh - There will be reputational impact of dissatisfied patients waiting in Emergency 6:00Department and potential financial risk of losing Pay-for-Results funding. 4:00Analysis 2:00There are challenges related to specialty consultations and Diagnostic Imaging 0:00procedures. Birchmount Campus TargetAction PlanInitiative Lead Date Initiated StatusLaboratory Technologists G. Bajwa Sep-09 OngoingGEM E. Laine Jun-09 OngoingNP LTC S. Vellani Jun-09 OngoingCharge Nurse and Triage RN Education L. Vanden Kroonenberg Mar-10 OngoingVirtual CDU implemented Dr T. Chan Apr-10 OngoingED PIP initiated N. Alli, T. Osgood May-10 In progressRounding for Outcomes M. Tang Jun-10 OngoingPerformance Huddles Leadership Team Jun-10 OngoingSchedule to Demand M. Tang Jan-11 Pending Page A2
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Emergency Department Wait Time for Low Acuity Visits - General CampusStrategic Direction Our PatientsTime Frame Q4 2010/11 (Jan)Source MOHLTC Wait Times Website / NACRSPerformance Measurement SummaryDefinitionThis indicator reports the 90th Percentile Wait time for all NonAdmit with CTAS 4-5visits. 06:37, n=5220 9:00 06:07, n=5325 05:54, n=4487 05:42, n=4779 05:37, n=5477 05:31, n=1245 8:00 05:12, n=4481Significance 04:48, n=3713This indicator is associated with efficiency within the ED and within the hospital, as 7:00well as with ED patient satisfaction. 6:00 5:00TargetMOHLTC Target - 4:00, lower value is desired. 4:00 CHART PLACEHOLDER 3:00Risk RatingHigh - There will be reputational impact of dissatisfied patients waiting in Emergency 2:00Department and potential financial risk of losing Pay-for-Results funding.Analysis 1:00There are challenges related to flow of patient treatment between major and minor 0:00cases. General Campus TargetAction PlanInitiative Lead Date Initiated StatusRPN Role D. Edman Jun-09 OngoingED PIP initiated J. Phan, N. Velosos Sep-09 OngoingSee and Treat Model of Care ED Staff Mar-10 In progressRounding for Outcomes D. Edman Jun-10 OngoingPerformance Huddles Leadership Team Jun-10 OngoingKaizen Events S. Gilbert Aug-10 In progress Page A3
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Emergency Department Wait Time for Low Acuity Visits - Birchmount CampusStrategic Direction Our PatientsTime Frame Q4 2010/11 (Jan)Source MOHLTC Wait Times Website / NACRSPerformance Measurement SummaryDefinitionThis indicator reports the 90th Percentile Wait time for all NonAdmit with CTAS 4-5visits. 06:37, n=3905 9:00 06:07, n=3811 05:54, n=3271 05:37, n=3894 8:00 05:18, n=3980 05:00, n=3950 04:57, n=1188Significance 04:30, n=3973This indicator is associated with efficiency within the ED and within the hospital, as 7:00well as with ED patient satisfaction. 6:00 5:00Target 4:00MOHLTC Target - 4:00, lower value is desired. CHART PLACEHOLDER 3:00Risk RatingHigh - There will be reputational impact of dissatisfied patients waiting in Emergency 2:00Department and potential financial risk of losing Pay-for-Results funding. 1:00AnalysisThere are challenges related to flow of patient treatment between major and minor 0:00cases. Birchmount TargetAction PlanInitiative Lead Date Initiated StatusRPN Role D. Edman Jun-09 OngoingED PIP initiated N. Alli, T. Osgood May-10 In progressRounding for Outcomes D. Edman Jun-10 OngoingPerformance Huddles Leadership Team Jun-10 OngoingSee and Treat Model of Care ED Staff Aug-10 In progress Page A4
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Percent of CTAS 1&2 meeting 8 hour targetStrategic Direction Our PatientsTime Frame Q4 2010/11 (Jan)Source MOHLTC Wait Times Website / NACRSPerformance Measurement SummaryDefinitionThis indicator reports the percentage of ED patients with CTAS 1 and 2 who 100% 73%, n=1413 73%, n=1401 71%, n=4200 71%, n=3733completed their visit (Registration to Leaving ED) within 8 hours. 71%, n=2787 70%, n=2332 69%, n=1203 69%, n=1228 69%, n=3248 69%, n=2045 68%, n=1854 68%, n=3057 68%, n=1203 90% 67%, n=1912 67%, n=3001 66%, n=3128 66%, n=1318 66%, n=1181 66%, n=1773 65%, n=1216 65%, n=2976 67%, n=855 64%, n=1795 65%, n=463 80%SignificanceTo ensure adequate patient access and flow within ED and hospital. 70% 60% 50%TargetMOHLTC Target - 90%, higher value is desired. 40% CHART PLACEHOLDER 30%Risk RatingHigh - There will be reputational impact of dissatisfied patients waiting in Emergency 20%Department and potential financial risk of losing Pay-for-Results funding.Analysis 10%There are challenges related to specialty consultations and Diagnostic Imaging 0%procedures. A Diagnostic Imaging Kaizen event is taking place to improveDiagnostic Imaging callbacks wait times. General Birchmount TSH TargetAction PlanInitiative Lead Date Initiated StatusED PIP initiated J. Phan Sep-09 OngoingGEM D. Driver Oct-09 OngoingCharge Nurse and Triage RN Education T. Reardon Mar-10 OngoingVirtual CDU implemented Dr T. Chan Apr-10 OngoingSchedule to Demand D. Edman Jun-10 CompletedRounding for Outcomes D. Edman Jun-10 OngoingPerformance Huddles Leadership Team Jun-10 OngoingNP LTC B. Bickle Jun-10 OngoingED PIP Kaizen Events S. Gilbert Aug-10 In progress Page A5
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Percent of CTAS 3 meeting 6 hour targetStrategic Direction Our PatientsTime Frame Q4 2010/11 (Jan)Source MOHLTC Wait Times Website / NACRSPerformance Measurement SummaryDefinitionThis indicator reports the percentage of ED patients with CTAS 3 who completed 100% 73%, n=4877 73%, n=8575 72%, n=3698 72%, n=4553their visit (Registration to Leaving ED) within 6 hours. 70%, n=7756 90% 67%, n=3203 67%, n=1486 66%, n=2653 66%, n=1167 65%, n=3784 65%, n=6914 65%, n=3130 63%, n=2771 61%, n=5821 61%, n=2837 60%, n=6218 60%, n=3381 60%, n=3050 60%, n=3399 59%, n=6120 58%, n=2563 80% 58%, n=2721 55%, n=5167Significance 51%, n=2604To ensure adequate patient access and flow within ED and hospital. 70% 60% 50%TargetMOHLTC Target - 90%, higher value is desired. 40% CHART PLACEHOLDERRisk Rating 30%High - There will be reputational impact of dissatisfied patients waiting in EmergencyDepartment and potential financial risk of losing Pay-for-Results funding. 20%Analysis 10%There are challenges related to specialty consultations and Diagnostic Imagingprocedures. A Diagnostic Imaging Kaizen event is taking place to improve 0%Diagnostic Imaging callbacks wait times. General Birchmount TSH TargetAction PlanInitiative Lead Date Initiated StatusED PIP initiated J. Phan Sep-09 OngoingGEM D. Driver Oct-09 OngoingCharge Nurse and Triage RN Education T. Reardon Mar-10 OngoingVirtual CDU implemented Dr T. Chan Apr-10 OngoingSchedule to Demand D. Edman Jun-10 CompletedRounding for Outcomes D. Edman Jun-10 OngoingPerformance Huddles Leadership Team Jun-10 OngoingNP LTC B. Bickle Jun-10 OngoingED PIP Kaizen Events S. Gilbert Aug-10 In progress Page A6
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Percent of CTAS 4&5 meeting 4 hour targetStrategic Direction Our PatientsTime Frame Q4 2010/11 (Jan)Source MOHLTC Wait Times Website / NACRSPerformance Measurement SummaryDefinition 79%, n=3600 81%, n=3253 80%, n=6853 82%, n=3101 85%, n=3438 84%, n=6539 79%, n=1965 80%, n=977 100% 76%, n=4280 76%, n=3093 78%, n=988 75%, n=3457 75%, n=7258This indicator reports the percentage of ED patients with CTAS 4 and 5 who 74%, n=6627 74%, n=2978 73%, n=5863 73%, n=3974 73%, n=3534 72%, n=3864 71%, n=2406 71%, n=6608completed their visit (Registration to Leaving ED) within 4 hours. 69%, n=6508 68%, n=2634 90% 66%, n=2644 80%SignificanceTo ensure adequate patient access and flow within ED and hospital. 70% 60% 50%Target 40%MOHLTC Target - 90%, higher value is desired. CHART PLACEHOLDER 30%Risk RatingHigh - There will be reputational impact of dissatisfied patients waiting in Emergency 20%Department and potential financial risk of losing Pay-for-Results funding. 10%AnalysisThere are challenges related to flow of patient treatment between major and minor 0%cases. Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11 (Jan) General Birchmount TSH TargetAction PlanInitiative Lead Date Initiated StatusRPN Role D. Edman Jun-09 OngoingED-PIP initiated J. Phan, N. Velosos Sep-09 OngoingSee and Treat Model of Care ED Staff Mar-10 In progressRounding for Outcomes D. Edman Jun-10 OngoingPerformance Huddles Leadership Team Jun-10 OngoingKaizen Events S. Gilbert Aug-10 In progress Page A7
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Rate of Hospital Acquired C. difficile Associated DiarrheaStrategic Direction Our PatientsTime Frame March 2011Source Surveillance and Case FindingPerformance Measurement SummaryDefinitionOverall Rate of hospital acquired C. difficile associated diarrhea. Rate is based on 0.70 0.58, n=5 0.58, n=5total number of inpatients/patients with confirmed infection per 1000 patient-days. 0.45, n=4 0.51, n=3 0.60 0.49, n=3 0.49, n=3 0.48, n=3 0.47, n=7 0.47, n=7 0.46, n=4 0.46, n=3 0.45, n=4Significance 0.43, n=6 0.40, n=6 0.45To track hospital acquired C. difficile rates in order to identify and implement 0.50 0.32, n=5 0.37, n=3 0.36, n=3infection control measures to prevent nosocomial spread of C. difficile. While C. 0.35, n=3 0.35, n=5 0.34, n=5 0.34, n=2difficile does not usually present a big problem for reasonably healthy adults, it can 0.33, n=2be quite serious for those who are frail or have other health challenges. 0.40 0.32 0.26, n=4 0.26, n=4 0.26, n=2Target 0.24, n=2 0.23, n=2 0.22, n=3 0.22, n=3 0.20, n=3 0.25Ontario Average - 0.28, lower value is desired. 0.30 0.22 0.16, n=1 0.15, n=1 0.15, n=2 CHART PLACEHOLDER 0.13, n=1 0.17 0.13, n=1Risk Rating 0.12, n=1 0.11, n=1 0.15Medium- Controlling the rate of infection is very important to TSH. The increase in 0.20 0.07, n=1 0.07, n=1the rate of infection may cause some financial and reputational risk to theorganization. 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 0.10AnalysisThere have been a few months of increased cases of C. difficile at the GeneralCampus since February 2010. Rates have begun to decline with increased -monitoring and vigilance of infection control practices in the inpatient areas. The Jul 10 Jan 10 Mar 10 Jan 11 Mar 11 Nov 09 Dec 09 Nov 10 Dec 10 Oct 09 Oct 10 Feb 10 Apr 10 Sep 10 Feb 11 May 10 Jun 10 Aug 10Birchmount Campus remains below the Ontario Average. General Campus Birchmount Campus TSH Ontario Average per 1,000 patient-days TSH Rolling 12-month AverageAction PlanInitiative Lead Date Initiated StatusIncreased vigilance to IPAC guidelines around C. difficile management for both campuses and enviromental E. Lipnicki Jan-11 Ongoingaudits of units"Vernacare" system for both campuses emphasizing safe disposable of wastes on units has been implemented E. Lipnicki Jun-10 CompletedProposal being made for an antimicrobial stewardship program to help decrease the use of antibiotics IPAC/Pharmacy Feb-11 In progressassociated with the development of C. difficile Page A8
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus (MRSA) BacteraemiaStrategic Direction Our PatientsTime Frame Q4 2010/11Source Surveillance and Case FindingPerformance Measurement SummaryDefinition 0.06 0.00, n=0Overall Rate of hospital acquired Methicillin Resistant Staphylococcus Aureus(MRSA) bacteraemia. Rate is based on total number of inpatients/patients withconfirmed infection per 1000 patient-days. 0.05 0.00, n=0 0.00, n=0 0.00, n=0SignificanceHigher MRSA colonization rates will lead to higher rates of blood stream infections 0.04with MRSA. Tracking hospital acquired MRSA Bacteraemia rates helps to identify 0.00, n=0the clinical significance of MRSA colonization. This will help identify a need for 0.00, n=0 0.00, n=0 0.00, n=0further strategies to prevent nosocomial spread of MRSA. 0.03TargetOntario Average - 0.02, lower value is desired. 0.02 CHART PLACEHOLDERRisk Ratingn/a 0.11, 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 0.00, 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 0.01Analysis 0.00Both General Campus and Birchmount Campus remains below the OntarioAverage. General Campus Birchmount Campus TSH Ontario Average per 1,000 patient-days TSH Rolling 12-month AverageAction PlanInitiative Lead Date Initiated StatusContinue with MRSA surveillance protocols E. Lipnicki Jul-10 OngoingBegin universal screening for MRSA colonization on admission IPAC Dec-10 In progress Page A9
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Rate of Hospital Acquired Vancomycin Resistant Enterococcus (VRE) BacteraemiaStrategic Direction Our PatientsTime Frame Q4 2010/11Source Surveillance and Case FindingPerformance Measurement SummaryDefinitionOverall Rate of hospital acquired Vancomycin Resistant Enterococcus (VRE) 0.012bacteraemia. Rate is based on total number of inpatients/patients with confirmedinfection per 1000 patient-days. 0.010SignificanceTo track hospital acquired VRE bacteraemia rates in order to identify and implement 0.008necessary prevention plans to reduce the risk of infection from spreading. 0.006Target 0.004Ontario Average - 0.00, lower value is desired. CHART PLACEHOLDER 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=0Risk Rating 0.002n/a 0.000AnalysisThere have been no reportable cases of VRE bacteraemia despite increasednumbers of VRE colonized patients since April 2010. General Campus Birchmount Campus TSH Ontario Average per 1,000 patient-days TSH Rolling 12-month AverageAction PlanInitiative Lead Date Initiated StatusVRE colonization outbreak over July 2010. Continue with IPAC protocols and ICRT recommendations for E. Lipnicki Apr-10 Completed July 2010surveillance and outbreak management policiesICRT invited for third party review July 20, 2010- waiting for final recommendations E. Lipnicki Jul-10 CompletedUniversal screening to be implemented to identify patients colonized with VRE on admission and thus reducenosocomial spread IPAC Dec-10 In progress Page A10
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Rate of Central Line Infection (CLI)Strategic Direction Our PatientsTime Frame Q4 2010/11Source Surveillance and Case FindingPerformance Measurement SummaryDefinition 6.32, n=6Overall rate of hospital acquired Central Line Infection. Rate is based on total 7.00number of CLI incidents diagnosed after two days of Critical Care admission per1000 patient days. 4.98, n=5 6.00 4.58, n=6Significance 3.90, n=6 5.00To track hospital acquired CLI rates in order to identify and implement necessaryprevention plans to reduce the risk of infection from spreading. 4.00 2.54, n=1 2.36, n=1 2.31, n=3 2.21, n=2 2.06, n=3Target 1.88, n=1 1.87, n=1 3.00Ontario Average - 0.75, lower value is desired. 1.48, n=3 CHART PLACEHOLDER 1.14, n=1Risk Rating 2.00 0.75, n=1 0.69, n=1 0.61, n=1n/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 1.00AnalysisThere has been a marked improvement to the number of CLI cases at TSH inJanuary 2011. CLI strategies to standardize processes across the campuses is 0.00showing improvements in the rates. Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11 General Campus Birchmount Campus TSH Ontario Average per 1,000 patient-days TSH Rolling 12-month AverageAction PlanInitiative Lead Date Initiated Status H. Clasky, D. Rose, S. Cesta, Jan-10 OngoingInterdisciplinary team meetings to standardize protocols at the Birchmount Campus including physician andnursing education R. Lovinsky H. Clasky, D. Rose, S. Cesta, Apr-10 CompletedChlohexidine dressings to help prevent CLIs R. Lovinsky H. Clasky, D. Rose, S. Cesta, Apr-10 OngoingOngoing monitoring of insertion and maintenance Bundle R. Lovinsky Page A11
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Rate of Ventilator Associated Pneumonia (VAP)Strategic Direction Our PatientsTime Frame Q4 2010/11Source Surveillance and Case FindingPerformance Measurement SummaryDefinition 4.56, n=2Overall Rate of hospital acquired Ventilator Associated Pneumonia. Rate is based 5.0on total number of VAP incidents diagnosed after two days of Critical Careadmission per 1000 patient days. 4.5 4.0SignificanceTo track hospital acquired VAP rates in order to identify and implement necessary 3.5 2.47, n=2prevention plans to reduce the risk of development of pneumonia in the ICU patientpopulation. 3.0 1.76, n=1 2.5 1.63, n=2 1.58, n=2 1.40, n=1Target 1.31, n=1 2.0 1.14, n=1Ontario Average - 1.46, lower value is desired. 0.97, n=1 CHART PLACEHOLDER 0.90, n=1 0.78, n=1 0.76, n=1 1.5Risk Ratingn/a 1.0 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=0Analysis 0.5There were no VAP cases identified at TSH in January 2011. 0.0 Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11 General Campus Birchmount Campus TSH Ontario Average per 1,000 patient-days TSH Rolling 12-month AverageAction PlanInitiative Lead Date Initiated StatusInterdisciplinary meeting with Birchmount Critical Care team to ensure compliance with safer healthcare bundle. Dr. Clasky, C. Shelton, S. Jan-11 In progressDevelopment of unit based scorecard to track progress. Ensure standardization between campuses. Cesta, R. LovinskyContinue monitoring compliance bundles (maintenance and insertion) J.MacIsasc Jan-11 In progress Page A12
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Rate of Timely Administration of Prophylactic Antibiotics - Primary Hip & KneeStrategic Direction Our PatientsTime Frame Q3 2010/11Source Medical Systems Management (OR System)Performance Measurement SummaryDefinition 95.7%, n=178 95.8%, n=249 99.2%, n=243 98.7%, n=74 99.1%, n=317 98.7%, n=231 99.0%, n=291 99.1%, n=216 98.3%, n=286 99.4%, n=155 98.2%, n=56 99.1%, n=211 97.3%, n=215 98.5%, n=64 97.6%, n=279 97.2%, n=205 98.0%, n=290 100.0%, n=60 100.0%, n=85 95.9%, n=71 95.9%, n=70Surgical site infections occur when harmful germs enter a patient’s body through the 120%surgical site (any cut the surgeon makes in the skin to perform the operation). Waysto prevent surgical site infections is by giving patients antibiotics 0 to 60 minutes or0 to 120 minutes (vancomycin antibiotic) before they undergo surgery. 100%SignificanceConducting post-surgical infection surveillance and measuring the application ofprophylactic antibiotics can be useful to enhance safety and quality of care, and to 80%prevent complications thereby decreasing morbidity and mortality rates. 60%TargetOntario Average - 96.1%, higher value is desired. CHART PLACEHOLDER 40%Risk Ratingn/a 20%AnalysisAll surgeons offices have pre-printed orders. Work continues on ensuring a goodprocess for improvement on this indicator. The drop at Birchmount Campus wasdue to one case where the patient received the antibiotic outside the recommended 0%time. This was because pre-op orders did not reference that Clindamychi must be Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11given 60 minutes pre-op. This has now been rectified. General Campus Birchmount Campus TSH Ontario Avg.TargetAction PlanInitiative Lead Date Initiated StatusEnsure compliance through audits PCMs Apr-09 In progressImplement standard order sets to improve compliance Nurse Educators Sep-09 Completed Page A13
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Wait Time - General SurgeryStrategic Direction Our PatientsTime Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPortPerformance Measurement SummaryDefinitionWait time is defined as the 90th percentile number of days between the date of 200decision to treat and the time the surgical procedure is performed. 180 160Significance 140A measure of access and efficiency for patients requiring these procedures. 88, n=524 87, n=499 84, n=279 120 83, n=419 82, n=356 75, n=397 75, n=415 68, n=279 68, n=475 67, n=314 67, n=457 100 61, n=387Target 80MOHLTC Target - 182, lower value is desired. CHART PLACEHOLDER 60Risk Ratingn/a 40 20AnalysisGeneral Surgery is performing well against Ontario average and provincial target. -Patients are seen in a timely manner. TSH Ontario TargetAction PlanInitiative Lead Date Initiated StatusHire of two new General Surgeons TSH Senior team Dec-09 CompletedContinue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Dec-10 OngoingAllocate OR time to services with wait time cases N. Rahim Dec-10 Ongoing Page A14
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Wait Time - Cancer SurgeryStrategic Direction Our PatientsTime Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPortPerformance Measurement SummaryDefinition 74, n=223Wait time is defined as the 90th percentile number of days between the date of 90decision to treat and the time the surgical procedure is performed. 65, n=267 80 60, n=217 59, n=192 57, n=191 54, n=173 70 53, n=234 50, n=169 49, n=221Significance 46, n=159A measure of access and efficiency for patients requiring these procedures. 60 43, n=100 50 40TargetMOHLTC Target - 84, lower value is desired. 30 CHART PLACEHOLDERRisk Rating 20n/a 10AnalysisCancer Surgery is performing well against Ontario average and provincial target. -Patients are seen in a timely manner. TSH Ontario TargetAction PlanInitiative Lead Date Initiated StatusContinue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Dec-10 OngoingAllocate OR time to services with wait time cases N. Rahim Dec-10 Ongoing Page A15
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Wait Time - Cataract SurgeryStrategic Direction Our PatientsTime Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPortPerformance Measurement SummaryDefinition 212, n=1368 223, n=1331 197, n=1438Wait time is defined as the 90th percentile number of days between the date of 250decision to treat and the time the surgical procedure is performed. 165, n=1134 157, n=1409 155, n=1434 150, n=1613 149, n=1325 145, n=1418 145, n=1453 200 138, n=1423Significance 123, n=1242A measure of access and efficiency for patients requiring these procedures. 150TargetMOHLTC Target - 182, lower value is desired. 100 CHART PLACEHOLDERRisk Ratingn/a 50AnalysisThe wait time for cataract surgery has decreased between January to February -2011 below the provincial target. Previous wait times was due to the lack of fundingfrom CE LHIN for 2010/11. Funded volumes have decreased for TSH by 315 casescompared to 2009/10. In Q4 the CE LHIN allocated additional 400 cataracts toassist TSH to bring down the 90th percentile for cataracts. The additional cataractvolumes have already impacted Januarys wait time. Q4 wait times will also be lowerthan Q3 due to data clean-up efforts undertaken. TSH Ontario TargetAction PlanInitiative Lead Date Initiated StatusContinue to monitor the performance of surgeons, wait time and OR blocks utilization N. Rahim Dec-10 OngoingAllocate OR time to services with wait time cases N. Rahim Dec-10 OngoingAllocate OR time to the Ophthalmology surgeons with wait times exceeding the WTIS target of 182 days N. Rahim Oct-10 In progressEnsure data quality check and re-education of Ophthalmology office staff to understand how to use of Decision N. Rahim Jan-11 In progressAffecting Readiness to Treat (DARTs) Option on patients Wait Time records Page A16
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Wait Time - Total Hip ReplacementStrategic Direction Our PatientsTime Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPortPerformance Measurement SummaryDefinitionWait time is defined as the 90th percentile number of days between the date of 250decision to treat and the time the surgical procedure is performed. 171, n=52 200 151, n=63 146, n=77 145, n=61Significance 131, n=64 130, n=50 124, n=57 123, n=43A measure of access and efficiency for patients requiring these procedures. 117, n=43 116, n=74 114, n=62 108, n=87 150Target 100MOHLTC Target - 182, lower value is desired. CHART PLACEHOLDERRisk Rating 50n/aAnalysis -Total Hip Replacement Surgery is performing well against Ontario average andprovincial target. Patients are seen in a timely manner. TSH Ontario TargetAction PlanInitiative Lead Date Initiated StatusContinue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Oct-09 OngoingAllocate OR time to services with wait time cases N. Rahim Dec-10 Ongoing Page A17
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Wait Time - Total Knee ReplacementStrategic Direction Our PatientsTime Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPortPerformance Measurement SummaryDefinitionWait time is defined as the 90th percentile number of days between the date of 250 192, n=202decision to treat and the time the surgical procedure is performed. 159, n=181 153, n=222 200 145, n=242Significance 130, n=159 124, n=221 124, n=236 124, n=222A measure of access and efficiency for patients requiring these procedures. 117, n=223 114, n=241 113, n=202 106, n=144 150Target 100MOHLTC Target - 182, lower value is desired. CHART PLACEHOLDERRisk Ratingn/a 50AnalysisTotal Knee Replacement Surgery is performing well against Ontario average and -provincial target. Patients are seen in a timely manner. TSH Ontario TargetAction PlanInitiative Lead Date Initiated StatusContinue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Oct-09 OngoingAllocate OR time to services with wait time cases N. Rahim Dec-10 Ongoing Page A18
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Wait Time - CTStrategic Direction Our PatientsTime Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPortPerformance Measurement SummaryDefinition 41, n=4757 50 39, n=5176Wait time is defined as the 90th percentile number of days wait for CT diagnostic 38, n=5105 38, n=5077scan. 36, n=5387 45 34, n=5091 32, n=5030 40 29, n=5169Significance 35Track the wait time indicators to ensure that we are meeting our MOHLTC 23, n=5177 23, n=5605 21, n=5510commitments and meeting the needs of our patients. 20, n=3968 30 25Target 20MOHLTC Target - 28, lower value is desired. 15 CHART PLACEHOLDERRisk Rating 10n/a 5AnalysisReduction 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, asmany requests involve the use of contrast media and these appointments arelimited. TSH Ontario TargetAction PlanInitiative Lead Date Initiated StatusWait time data entry training for booking clerks V. Winters Nov-09 CompletedWTIS data error resolution done on a monthly basis - indicates data entry errors - follow up with staff Charge clerks Nov-09 In progressApplication for second CT at General Campus in Satellite location; will decrease all Wait Times T. Jackson Sep-10 PendingReview existing contrast media delivery policy and explore options for extending contrast appointments T. Jackson Sep-10 Pending Page A19
    • The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Wait Time - MRIStrategic Direction Our PatientsTime Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPortPerformance Measurement SummaryDefinition 118, n=2240 133, n=2121 116, n=2132 109, n=2028 140 107, n=2085Wait time is defined as the 90th percentile number of days wait for MRI diagnostic 103, n=1895 101, n=1718scan. 99, n=1844 99, n=1954 120 79, n=1744Significance 100Track the wait time indicators to ensure that we are meeting our MOHLTC 64, n=1635 61, n=1844commitments and meeting the needs of our patients. 80Target 60MOHLTC Target - 28, lower value is desired. CHART PLACEHOLDER 40Risk RatingMedium - delays can affect patient care. P4 are the lowest priority. Long waits can 20negatively impact reputation.Analysis -MOHLTC target for priority 4 cases is 28 days and the CELHIN has a target of 76.5days. Currently exceeding both. Demand for services continues to outstripavailable resources. Current MRI Process Improvement Project (PIP) process isreviewing scheduling process for efficiencies. TSH receieved funding from CELHINin Q4 for 360 additional MRI hours in hopes of decreasing wait times. TSH Ontario TargetAction PlanInitiative Lead Date Initiated StatusWait time data entry training for booking clerks V. Winters Nov-09 CompletedWTIS data error resolution done on a monthly basis - indicates data entry errors - follow up with staff Charge clerks Nov-09 In progressMRI PIP- LEAN process for identifying improvements in MRI throughput S. Porter Jun-10 In progressSecond MRI application sent to CELHIN, LHIN approval moved to MOHLTC T. Jackson Jul-10 In progressOperating hours extended to 24hrs during weekdays for Q4 2010/11 S. Porter Jan-11 In progress Page A20
    • The Scarborough Hospital Corporate Balanced ScorecardIndicator Patient satisfaction - Overall Impression (Emergency Department and In-patients)Strategic Direction Our PatientsTime Frame Q3 2010/11Source NRC PickerPerformance Measurement SummaryDefinitionResponse to Overall Impression questions in NRC Picker survey administered to a 100sample of discharged Emergency Department patients and In-patients:- Emergency Department (ED): Would you recommend TSH for Emergency 67.2 n=271Department services? 62.6 n=342 61.9 n=318- Inpatients: Would you recommend TSH for an In-patient stay? 80 60.9 n=322 60.4 n=359 59.3 n=327 59.4 n=330Significance 49.7 n=193 49.1 n=116 48.3 n=143 46.8 n=154This indicator is a measure of patients overall impression of the quality of care 44.3 n=212received. 60 41.5 n=135 36.4 n=151TargetTSH target is 50 for ED and 73 for IP, higher value is desired. The target is basedon GTA average. 40 CHART PLACEHOLDERRisk RatingHigh- Reputational, financial or operational risk. 20AnalysisTSH Emergency Department satisfaction scores is below the target. TSH Inpatientsatisfaction scores continue to be below other Greater Toronto Area hospitals. TSHhas made positive changes such as Code of Conduct, and faster response time to 0patient complaint by Patient Relations department. Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 ED Score IP Score Target - GTA ED Avg Target - GTA IP AvgAction PlanInitiative Lead Date Initiated StatusQCIPA Reviews ED Leadership Team Sep-10 Ongoing• QCIPA case reviews take place whenever an incident, near miss or adverse event occurs• Recommendations are shared with staffTeam Charter, the ED Team Charter defines the purpose of the team, how we all work together and what the Nursing Leadership Team and Sep-10 Ongoingexpected outcomes will be: ED staff• Utilized to lay the foundation of expected team behaviours• Utilized to guide staff in their performance and interactions with patientsHiring the right people for the team. The ED will recruit and retain professionals with the right level of knowledge, D. Edman and T. Reardon Sep-10 Ongoingtechnical expertise and interpersonal skill.• Select new staff who will make a positive difference to our patients• Select staff who support our mission, vision and values Page 2
    • Staff Education, all staff are giving an opportunity to enhance or increase their knowledge and skill: S. Gilbert and L. Vanden Sep-10 Ongoing• Charge Nurse workshops Kroonenberg• Triage Nurse workshops• Monthly inservicing on selected topics• Customer service educationPatient friendly waiting room D. Edman and T. Reardon Sep-10 Completed for General CampusGeneral Campus:• ED Activity board in place to inform patients in the waiting room about potential wait time• Wayfinding steps to triage, registration and wait room in place to ensure patients queue appropriatelyBirchmount Campus• Re-design waiting room, triage and registration in process• ED activity board in processFast track RAZ patients D. Edman and N. Alli Sep-10 Completed for BirchmountGeneral Campus: Campus• Elite RAZ staff• Number system to ensure patients are aware of who is next in line• Pull to RAZ waiting roomBirchmount Campus:• Elite RAZ staff• Pull to RAZ waiting room Page 3
    • The Scarborough Hospital Corporate Balanced ScorecardIndicator Percentage of publicly reported patient safety indicators meeting the provincial target (see addendum)Strategic Direction Our PatientsTime Frame Q3 2010/11Source Meditech, NACRS, IPAC, MOHLTC Wait Times Public WebsitePerformance Measurement SummaryDefinition 120%Percentage of 19 publicly reported patient safety indicators that meet the provincialtargets.Significance 100%Provides information on patient safety issues where the goal is to enhance patientsafety in the hospital by reducing the risk factors. Monitoring these indicators in thehospital is a priority and is key to keeping patients safe. 63%, n=12 63%, n=12 63%, n=12 80% 58%, n=11Target 53%, n=10TSH Target - 100%, higher value is desired.Risk Ratingn/a 60%Analysis CHART PLACEHOLDER• There continues to be improvement in our high and low acuity scores at both theGeneral and Birchmount campus compared to a year ago. 40%• 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 controlpractices in the inpatient areas. The Birchmount campus remains below the Ontario 20%average.• There has been a decrease in the number of CLI cases at the Birchmount campus.Overall, TSH remains below the Ontario average. Standardization of CLI strategiesacross the campuses will assist in decreasing CLI cases across TSH. 0%• There has been some decrease in VAP cases identified at the General campus and Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11Birchmount campus in the last quarter. Both campuses are now below the Ontarioaverage.• SSI - Antibiotics Timing - Hip/Knee: Work continues on ensuring a good process for % patient safety indicators meeting provincial targets Targetimprovement on this indicator.• TSH patients continue to receive timely access to care. TSH wait time for general surgery, hip/knee, CT is below the provincial average.• The wait time for MRI is above the Ontario average, however, the wait time has increased to 116 in Q3 2010/11.• The wait time for cataract surgery has increased in Q3 2010/11 above the provincial target. There is a lack of funding from CE LHIN for 2010/11. Funded volumes have decreased for TSH by 315cases compared to 2009/10. Wait time for cataracts will continue to increase unless additional funding is received.Action PlanInitiative Lead Date Initiated StatusImplement standard order sets to improve compliance Nurse Educators Sep-09 CompletedEarly cluster identification and interventions including unit terminal cleaning, use of vernacare system, re- IPAC Sep-09 Ongoingenforcement/education on hand hygiene, cleaning of equipments between patients and prudent use of antibioticsContinue to monitor CLI and VAP bundle compliance in Intensive Care Unit Dr. I. Daves, B. Westcott, IPAC Sep-09 OngoingAn additional 300 hours of wait time funding accepted from CE LHIN reallocation. Implementation of expanded T. Jackson Sep-09 - Mar-10 Completedhours of operation to commence Sep-09Interdisciplinary meeting with Birchmount critical care team to ensure compliance with safer healthcare bundle. Dr. Clasky, C. Shelton, S. Cesta, Jan-10 In progressDevelopment of unit based scorecard to track progress. Ensure standardization between campuses R. Lovinsky Page 4
    • Continue with notification to pharmacy regarding patient’s with diarrhea, early use additional precautions on IPAC Jan-10 Ongoingsymptomatic patients until C. Diff is ruled out and standardization of cleaning protocols and products for bothcampusesIncreased vigilence to IPAC guidelines around C. Diff management for both campuses E. Lipnicki Feb-10 OngoingRe institution of the Antibiotic Stewardship Committee to ensure prudent use of antibiotics. Development of a IPAC Feb-10 In progresscorporate policy for cleaning and disinfecting shared equipments and separation of clean and soiled utility room.Plan for increase vernacare waste maceratorsCollaborate with IPAC, Critical Care, Diagnostic Imaging, IV resource and Physician team on type of line to be B. Westcott, Dr. H. Clasky, Dr. R. Feb-10 In progressinserted, compliance with insertion and maintenance bundles. Focus on hand hygiene improvement, reinforce Lovinsky, IPACimportance of aseptic line access, timely removal of central lines, educate Physicians on line removal, empowernurses to prompt line discontinuation, improve line documentationContinue to ensure compliance with SSI - Antibiotics Timing (Hip/Knee). Overall compliance rate is currently N. Rahim Feb-10 Ongoing99%With the addition of 3 General surgeons, access to care should further improve. Continue to monitor wait times N. Rahim Feb-10 Ongoingand ensure TSH is meeting funded volumesContinue to deliver cataract surgery to funded volumes only. Funding for an additional 123 cases has been N. Rahim Feb-10 Ongoingreceived. This volume has already been delivered. Additional finding of 375 cases requested from the CE LHINInvestigate feasibility of extending contrast cases to off-hours: Not supported at this time T. Jackson Feb-10 CompletedPursue 2nd CT scanner to increase capacity: Not approved to commence procurement. Linked to achievement of T. Jackson Feb-10 Pendingagreed upon nuclear cardiology referral volumes, which have not yet been metED Process Improvement Project (PIP) has re-designed the Rapid Assessment Zone (RAZ) for a team approach L. Crawford, A. MacKinnon, J. Mar-10 Completedto see and treat PhanClinical Decision Unit (CDU) L. Crawford, Dr. T. Chan Mar-10 CompletedVirtual CDU L. Crawford, Dr. T. Chan Mar-10 OngoingVRE colonization outbreak over Jul-10. Continue with IPAC protocols and ICRT recommendations for E. Lipnicki Apr-10 Completedsurveillance and outbreak management policiesContinue to work with the Antibiotic Stewardship Committee to ensure prudent use of antibiotics to lower and IPAC, Dr. R. Lovinsky May-10 In progressmaintain rates below the provincial averageCLI Rates beginning to drop with subsequent months for the General campus. Continue to monitor progress and B. Westcott, Dr. H. Clasky, Dr. R. May-10 In progresscollaborative work as outlined below Lovinsky, IPACED PIP L. Crawford, A. MacKinnon, Dr. T. May-10 – General In progress Chan Dec-10 – BirchmountStaffing demand for nursing and physicians. Master schedule for nursing staff to be implemented June 21, 2010 L. Crawford, A. MacKinnon, D. Jun-10 Ready for implementation Edman, Dr. T. ChanReview of "vernacare" system for both campuses emphasizing safe disposal of waste. 4 new vernacare units E. Lipnicki Jun-10 In progressapproved for Birchmount campus in 2010 capital planMRI PIP - LEAN process for identifying improvements in MRI throughput S. Porter Jun-10 In progressContinue with MRSA surveillance protocols E. Lipnicki Jul-10 OngoingICRT invited for third party review July 20, 2010 - waiting for final recommendations E. Lipnicki Jul-10 CompletedSecond MRI application sent to CE LHIN, LHIN approval moved to MOHLTC T. Jackson Jul-10 In progressPay for Performance (P4R) funding received for year III: Electronic Bed Board; Clinical Facilitator; Laboratory L. Crawford, A. MacKinnon, Dr. T. Fall 2010 In progressTechnologists; See and Treat; Staff to Demand; Rapid Admissions Unit (RAU); LEAN; ED PIP extension ChanED PIP commenced Apr-10 at the Birchmount campus. Value Stream Mapping (VSM) completed. Entering L. Crawford,A. MacKinnon, N. Alli Sep-10 In progresssolution design stage with launch on May 26, 2010RAU L. Crawford, A. MacKinnon, N. To be integrated into base – Sep- Ongoing Veloso 10ED wait times may not be met due to influenza surge during Q3. Cataract surgery wait times down to below E. Lipnicki Feb-11 Ongoingtarget after significant clean up of wait time data in surgeons offices completed by TSH staff. Continue withadditional cleaning of C-diff affected units and auditing of infection control practices on these units. Plans in theworks for additional MRI scanner installation at Birchmount summer 2011. This will help reduce MRI wait time Page 5
    • The Scarborough Hospital Corporate Balanced ScorecardIndicator Number of incident reports completed (medication and non-medication)Strategic Direction Our PatientsTime Frame Q4 2010/11 (projected based on Jan-Feb 2011)Source S.A.F.E. (rLSolutions)Performance Measurement SummaryDefinition 800 743Incident reports are one mechanism to capture the occurence of an actual or 730 705potential adverse event in an organization (others include chart reviews, patientcomplaints, etc.). An online webbased system (S.A.F.E.) provided by RL Solutions 700 626is used at TSH to report patient, visitor and staff actual and potential adverse events 576as well as track follow-up actions for these events. 600 521Significance 467To track trends in adverse events in order to identify and implement necessary 500improvement plans. 403Target 400TSH Target - 490, higher value is desired. The target for this indicator has beenestablished as a 5% increase from the corresponding quarter in the previous fiscalyear. 300 CHART PLACEHOLDERRisk Ratingn/a 200Analysis 100TSH is currently meeting target in this quarter. The experience in Canadian andU.S. hospitals is that adverse events are underreported and it can be assumed that 0TSH is no different. Therefore, the objective is to increase incident reporting, as Q1 Q2 Q3 Q4 (projected based onleast in the short term. Jan-Feb 2011) 2009/10 2010/11 TargetAction PlanInitiative Lead Date Initiated StatusMonthly reports provided to each PSG director Performance & Decision Support Apr-10 OngoingQuality of Care Committee reviews critical incident reports at each meeting and tracks status of C. Hendriks Oct-10 OngoingrecommendationsRisk Management making regular report on incident trends and critical incidents quarterly to MAC C. Hendriks Oct-10 Ongoing Page 6
    • The Scarborough Hospital Corporate Balanced ScorecardIndicator Hospital Standardized Mortality Ratio (HSMR)Strategic Direction Our PatientsTime Frame 2010/11 (Apr-Dec)Source The Canadian Institute for Health Information (CIHI)Performance Measurement SummaryDefinitionThe ratio of actual in-hospital deaths to the expected number of in-hospital deaths 160for conditions that account for 80% of in-patient mortality. Where a HSMR score of 137 132 131100 represents the actual number of deaths equal to the expected number of 129 140 127 126 124 122 122deaths. A number above 100 indicates a higher than expected number of deaths 120 114 114and a number below 100 indicates a lower than expected number of deaths. 112 112 109 120 106 105 97 100 84 88Significance 80 75This is a global indicator for patient safety and the quality of care provided within a 74 73 80facility. 60 CHART PLACEHOLDERTargetTSH Target - 100, lower value is desired. 40Risk Ratingn/a 20Analysis 0The 2009/10 year-end TSH HSMR showed dramatic improvement with the publicly 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11released value of 84. We now rank within the top 10 in the GTA and 4th amongst (Apr-Dec)peer community hospitals. General Birchmount TSH TargetAction PlanInitiative Lead Date Initiated StatusThe following initiatives are underway: Dr. S. Jackson Feb-10 Ongoing• Mortality Chart Review (current)• Quality of Care Committee (Feb-10)• Face Sheet implemented Nov-10• Hospitalists 4 in place on 2 wards as of Feb-11 Page 7
    • The Scarborough Hospital Corporate Balanced ScorecardIndicator Rate of hand hygiene complianceStrategic Direction Our PatientsTime Frame Q3 2010/11Source Surveillance and Case FindingPerformance Measurement SummaryDefinition 99%, n=655 98%, n=1534 98%, n=2430 96%, n=4248 98%, n=644 97%, n=879 94%, n=2334 120% 94%, n=1818 93%, n=1464 96%, n=491 92%, n=4049The single most common way of transferring health care-associated infections (HAIs) 90%, n=1715 90%, n=384 90%, n=820 90%, n=463 89%, n=875in health care settings is on the hands of health care providers. Health care providers 85%, n=803move from patient to patient and room to room while providing care and working in the 81%, n=340patient environment. This movement provides many opportunities for the transmission 100%of organisms on hands that can cause infections. 80%SignificanceProper hand hygiene protects patients and providers and will reduce the spread ofinfections and the associated treatment costs, reduce hospital lengths of stay andreadmissions, reduce wait times, and prevent deaths. 60%Target. 40% CHART PLACEHOLDEROntario Target - 90% Before and 90% After, higher value is desired.Risk Rating 20%n/aAnalysis 0%Due to the lack of modified workers and the VRE issue, there were not enough audits Before After Before After Before Afterdone to report for Q3 at the General Campus. The data for the Birchmount Campusexceeds the target for After care. 2008/09 2009/10 2010/11 General Campus Birchmount Campus TSH TargetAction PlanInitiative Lead Date Initiated StatusContinue with the development of a unit based hand hygiene program overseen by IPAC N. Vankoosingh Jul-10 In progress Page 8
    • The Scarborough Hospital Corporate Balanced ScorecardIndicator Employee Satisfaction survey results (Commitment composite score)Strategic Direction Our PeopleTime Frame 2010/11Source NRC PickerPerformance Measurement SummaryDefinition 50.9%, n=1590 60%The Employee Opinion Survey measures employee satisfaction on various scales.Employee Commitment composite score is shown on the scorecard. Scores are outof 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 37.5%, n=1606 50%values/organizations values are similar iv) Organization inspires best in you v) Gladchose organization over others. 40%SignificanceTo track trends in employee satisfaction in order to identify and implementnecessary improvement plans. 30% CHART PLACEHOLDERTargetOntario Average - 59% for 2010/11 and 55% for 2008/09, higher value is desired. 20%Risk Ratingn/a 10%AnalysisAll Hospital Average commitment scores for employees is 59.4% and Physician AllHospital Average for commitment is 43.1%. EOS increased by 13.1% and POS by 0%13.9%. Although we did not meet the target of 55% ,our data clearly indicates a 2008/09 2010/11statistically significant positive trend in commitment. Addressing prioritized areas ofimprovement both at the Corporate and unit level will continue to positively impact Commitment Score Targetcommitment scores going forward.Action PlanInitiative Lead Date Initiated StatusViolence in the Workplace- Organized polices; Code White, harassment, discrimination, code of conduct and S. Rai-Lewis Mar-10 Completedviolence in the workplace under one heading – Respect in The Workplace. Rollout of training on Bill 168 to becompleted in June. Ongoing training through learning institiuteEmployee Opinion Survey to be administered every 2 years, next full survey will be September 2010 S. Rai-Lewis Sep-10 CompletedIntroduce Pulse Survey to measure engagement (quarterly snapshot) S. Rai-Lewis Fall 2011 Scheduled for Fall 2011 Page 9
    • The Scarborough Hospital Corporate Balanced ScorecardIndicator Physician Satisfaction survey results (Commitment composite score)Strategic Direction Our PeopleTime Frame 2010/11Source NRC PickerPerformance Measurement SummaryDefinition 60%The Physician Opinion Survey measures physician satisfaction on various scales.The physician commitment composite score is shown on the scorecard. Scores are 42.7%, n=151out 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 50%values/organizations values are similar iv) Organization inspires best in you v) Gladchose organization over others. 28.8%, n=141 40%SignificanceTo track trends in physician satisfaction in order to identify and implement 30%necessary improvement plans. CHART PLACEHOLDERTarget 20%Ontario Average - 43% for 2010/11 and 45% for 2008/09, higher value is desired.Risk Rating 10%n/aAnalysis 0%The 2010 survey shows dramatic improvement as compared to 2008. The 2010 2008/09 2010/11commitment score of 42.7 is now comparable to the hospital average. Commitment Score TargetAction PlanInitiative Lead Date Initiated StatusPerformance review taking into account values including code of conduct Dr. S. Jackson Apr-10 OngoingDevelopment of robust communication with family physicians Dr. S. Jackson Apr-10 OngoingThe development of the The Clinical Services Plan Dr. S. Jackson Apr-10 OngoingThe development of Physician leadership award Dr. S. Jackson Apr-10 Ongoing Page 10
    • The Scarborough Hospital Corporate Balanced ScorecardIndicator Percentage of defined Model of Care positions transitionedStrategic Direction Our PeopleTime Frame 2010/11Source Internal TrackingPerformance Measurement SummaryDefinition 100%, n=21 120%Percentage of clinical resource staff (i.e. nurse educators and nurse clinician) whohave transitioned and are functioning in the new Clinical Resource Leader role. 100%SignificanceModel of Care positions supports excellent care and full scope of practice andenhances partnerships between practice and operations. 80%Target 60%100% CHART PLACEHOLDERRisk Rating 40%n/aAnalysis 20%All positions have been transitioned and all are functioning in the role. 0% 2010/11 % positions transitioned TargetAction PlanInitiative Lead Date Initiated StatusTransition of clinical resource staff to the new Clinical Resource Leader role R. Seidman-Carlson Apr-10 Completed Page 11
    • The Scarborough Hospital Corporate Balanced ScorecardIndicator Percentage of Medical Directors with completed performance evaluationsStrategic Direction Our PeopleTime Frame Q3 2010/11Source Internal TrackingPerformance Measurement SummaryDefinition 120%Percentage of Medical Directors with completed annual performance evaluations.Percentage based on total number of Medical Directors in the hospital. 100% 80%, n=8SignificanceEmployee evaluation is important for development of staff and managers to beaware of employee development needs. 80%Target 60%Internal Target - 100%, higher value is desired. CHART PLACEHOLDERRisk Rating 40%n/aAnalysis 20%Performance evaluations are on track to be completed by the end of the fiscal year. 0% Q3 2010/11 % Medical Directors with completed evaluation TargetAction PlanInitiative Lead Date Initiated StatusInitialization of Medical Directors performance and evaluations Dr. S. Jackson Apr-10 Ongoing Page 12
    • The Scarborough Hospital Corporate Balanced ScorecardIndicator HIT indicator #17, Percentage of equipment cost to total expenseStrategic Direction Our Programs, Plans and PartnersTime Frame 2010/11 (Apr-Sept)Source Healthcare Indicator Tool (HIT)Performance Measurement SummaryDefinitionTotal equipment cost (including depreciation rental/lease and maintentance cost) as 7.0% 6.2% 6.2%a percent of total hospital expense. 5.6% 5.4% 6.0% 5.2% 5.2%SignificanceTo track our investment in equipment and technology in comparison to our industry. 5.0% 4.0%Target 3.0%LHIN Average - 5.9%, target value is desired. CHART PLACEHOLDERRisk Rating 2.0%Medium - Impact would be operational (i.e. quality). 1.0%AnalysisLack of investment in equipment and technology may impact quality of care andperformance. Equipment depreciation has declined due to delay in acquisition of 0.0%new equipment (i.e. CTs). 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 (Apr- Sept) % of equipment cost to total expense TargetAction PlanInitiative Lead Date Initiated StatusExpedite acquisition of major pieces of equipment included in 2010/11 Capital Plan R. Anstey Feb-11 In progress Page 13
    • The Scarborough Hospital Corporate Balanced ScorecardIndicator Percentage of PMO project milestones metStrategic Direction Our Programs, Plans, and PartnersTime Frame Q3 2010/11Source Eclipse project management applicationPerformance Measurement SummaryDefinitionA number of initiatives for the department have been agreed upon at the outset of 120% 96%, n=22 94%, n=15the fiscal year. Each initiative has milestones that must be achieved. This measurerepresents all milestones achieved for all initiatives as a percentage. 100%SignificanceA measure of department performance, efficiency and planning. 80% 47%, n=20 60%TargetInternal Target - 80%, higher value is desired. CHART PLACEHOLDER 40%Risk RatingMedium- Reputational, financial or operational risk. 20%AnalysisIn Q3 2010/11, fourty-three milestones were being tracked by the PMO. In thisquarter, 20 of 43 milestones have been met. 0% Q1 2010/11 Q2 2010/11 Q3 2010/11 % milestones achieved TargetAction PlanInitiative Lead Date Initiated StatusMonthly status reports required from each project manager to report on project status, met and missed J. Cox Sep-10 Ongoingmilestone, project risksPMO Advisory Committee Coach assigned to each project to provide advice on Status Report content C. Flemming Sep-10 OngoingInventory of task timelines being development to guide future project plans (e.g. RFP development and positng, J. Cox Oct-10 Ongoingcontract negotiation, hardware procurement)PMO Lead reviewing all project milestones to ensure they meet the milestone definition and that there are J. Cox Oct-10 Ongoingsufficient milestones to track the project. Feedback provided to project managersLargest proportion of missed milestones were presentation of Business Cases. These presentations are C. Flemming Feb-11 Ongoingscheduled for March 7 Page 14
    • The Scarborough Hospital Corporate Balanced ScorecardIndicator Percentage of Programs and Departments with performance indicator scorecards and action plans that are posted and updated quarterly on the IntranetStrategic Direction Our PerformanceTime Frame Q3 2010/11Source Performance & Decision SupportPerformance Measurement SummaryDefinitionA Corporate Scorecard (1) has been developed, along with scorecards for each 120%VP/ED portfolio (7), PSG and clinical support department (12). This measurereflects whether the scorecards (including action plans) were published and posted 85%, n=17on the SharePoint. 100% 75%, n=15 75%, n=15SignificanceRoutine uploading of scorecards will facilitate regular review of the indicators andtransparency to the staff and other departments. 80%Target 60%Internal Target - 100%, higher value is desired. CHART PLACEHOLDERRisk Rating 40%n/aAnalysis 20%A schedule has been developed for VP/ED scorecard reporting at the weekly SeniorManagement Team (SMT) meeting. The Performance & Decision Support PDSconsultant is responsible for building and maintaining scorecards for their respective 0%PSGs on a quarterly basis. There are a total of 20 Scorecards (1 Corporate, 7 Q1 2010/11 Q2 2010/11 Q3 2010/11VP/ED, and 12 PSG/Depart.). % of posted scorecards TargetAction PlanInitiative Lead Date Initiated StatusVP/ED Scorecard SMT presentation schedule established C. Flemming Aug-10 CompletedVP/ED Scorecards to be sent to PDS upon completion for publication on the PDS SharePoint site C. Flemming Aug-10 PendingDiscuss QIP and VP/ED Scorecards at March SMT meeting C. Flemming Feb-11 Pending Page 15
    • The Scarborough Hospital Corporate Balanced ScorecardIndicator Total marginStrategic Direction Our PerformanceTime Frame 2010/11 (Apr-Jan)Source FinancePerformance Measurement SummaryDefinitionTotal margin is the percentage by which total revenues exceed or fall short of total 1.00%expenses. A positive percent indicates an operating surplus position where anegative percent reflects an operating deficit position. 0.50%SignificanceTo ensure the Hospital is operating in a balanced or surplus position. 0.00% 2006/07 2007/08 2008/09 2009/10 2010/11 (Apr-Jan)Target -0.50%TSH Target - 0%, target value is desired. CHART PLACEHOLDERRisk Ratingn/a -1.00%AnalysisApril to January result of 0.30% reflects a surplus of $690K for the first 9 months of -1.50%2010/11. -2.00% Total Margin TargetAction PlanInitiative Lead Date Initiated StatusQuarterly review by Senior Management Team to ensure a total margin of 0% or better is maintained R. Anstey Jul-10 In progress Page 16
    • The Scarborough Hospital Corporate Balanced ScorecardIndicator Percentage of accountability agreement indicators achievedStrategic Direction Our PerformanceTime Frame Q3 2010/11Source FinancePerformance Measurement SummaryDefinition 100%, n=8 120%Overall percent achievement of 8 accountability agreement indicators:(Total Margin, Current Ratio, % FT Nurses, Weighted Cases, MH Patient Days, 88%, n=7 88%, n=7 88%, n=7Rehab Patient Days, ER Visits, Amb Visits). 100% 75%, n=6 75%, n=6SignificanceTrack volumes for the indicators in the Hospitals Accountability Agreement toensure that we are meeting our MOHLTC commitments. 80% 60%TargetTSH Target - 80%, higher value is desired. CHART PLACEHOLDER 40%Risk Ratingn/a 20%AnalysisIn Q3 the rehab Patient days target has not been achieved as we are experiencing adecline in this service as patients are being discharged earlier and rehab is takingplace on an outpatient basis or at a designated rehab facility. There are possible 0%financial penalties associated with not meeting accountability agreement 2007/08 2008/09 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11commitments. % accountability agreement indicators achieved TargetAction PlanInitiative Lead Date Initiated StatusContinue to monitor financial results R. Anstey Jul-10 In progressInvestigate Rehab patient day volumes R. Anstey, E. Lipnicki Aug-10 In progress Page 17