The Scarborough Hospital                                                                                                  ...
The Scarborough Hospital                                                                                                  ...
The Scarborough Hospital                                                                         Corporate Balanced Scorec...
The Scarborough Hospital                                                                         Corporate Balanced Scorec...
The Scarborough Hospital                                                                         Corporate Balanced Scorec...
The Scarborough Hospital                                                                         Corporate Balanced Scorec...
The Scarborough Hospital                                                                       Corporate Balanced Scorecar...
The Scarborough Hospital                                                                       Corporate Balanced Scorecar...
The Scarborough Hospital                                                                       Corporate Balanced Scorecar...
The Scarborough Hospital                                                                         Corporate Balanced Scorec...
The Scarborough Hospital                                                                       Corporate Balanced Scorecar...
The Scarborough Hospital                                                                      Corporate Balanced Scorecard...
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
Tsh scorecard   corporate - 2010 11 q3 d
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Tsh scorecard corporate - 2010 11 q3 d

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Tsh scorecard corporate - 2010 11 q3 d

  1. 1. 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
  2. 2. 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 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
  3. 3. 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 EmergencyDepartment and potential financial risk of losing Pay-for-Results funding. 4:00Analysis 2:00There are challenges related to discharge processes, bed turnover times, and bedavailability. As a result of ED PIP, white boards, discharge huddles, patient 0:00education 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
  4. 4. 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 20:00 13:36, n=6812Significance 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
  5. 5. 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 8:00 05:31, n=1245 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
  6. 6. 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 7:00 04:30, n=3973This indicator is associated with efficiency within the ED and within the hospital, aswell 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. 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
  7. 7. 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=1228 69%, n=1203 69%, n=3248 69%, n=2045 90% 68%, n=1854 68%, n=3057 68%, n=1203 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
  8. 8. 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 80% 59%, n=6120 58%, n=2563 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
  9. 9. 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=988This indicator reports the percentage of ED patients with CTAS 4 and 5 who 75%, n=3457 75%, n=7258 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 90% 68%, n=2634 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
  10. 10. The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety IndicatorsIndicator Rate of Hospital Acquired C. difficile Associated DiarrheaStrategic Direction Our PatientsTime Frame May 2011Source Surveillance and Case FindingPerformance Measurement SummaryDefinition 1.09, n=9Overall Rate of hospital acquired C. difficile associated diarrhea. Rate is based on 1.20total number of inpatients/patients with confirmed infection per 1000 patient-days. 1.00 0.78, n=11SignificanceTo track hospital acquired C. difficile rates in order to identify and implementinfection control measures to prevent nosocomial spread of C. difficile. While C. 0.80 0.58, n=5 0.58, n=5difficile does not usually present a big problem for reasonably healthy adults, it can 0.53, n=5 0.43,0.51, n=3be quite serious for those who are frail or have other health challenges. 0.49, n=3 0.49, n=3 0.35, n=3 n=3 0.48, n=4 0.47, n=7 0.47, n=7 0.47, n=7 0.47, n=3 0.46, n=4 0.26, n=4 0.46, n=3 0.15, n=10.32, n=5 n=4 0.45, n=4 0.60 n=6Target 0.40, n=6 0.48, 0.15, n=1 0.38, n=6 0.45, 0.37, n=3 0.36, n=3Ontario Average - 0.28, lower value is desired. 0.35, n=5 0.34, n=2 0.34, n=5 0.13, n=1 0.34, n=2 0.33, n=2 0.26, n=4 0.26, n=2 CHART PLACEHOLDER 0.17, n=1 n=2 0.24, n=2 0.23, n=2 0.40 0.22, n=3 0.00, n=0 0.22, n=3 0.22, n=3Risk Rating 0.20, n=3 0.25, 0.16, n=1Medium- Controlling the rate of infection is very important to TSH. The increase in 0.15, n=2 0.13, n=1 0.12, n=1 0.11, n=1the rate of infection may cause some financial and reputational risk to the 0.00, n=0 n=1 0.00, n=0n=1organization. 0.20 0.00, n=0 0.00, n=0 0.00, n=0 0.00, n=0 0.00, n=0 0.00, n=0 0.07, 0.07,AnalysisThere 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 Oct 09 Oct 10 Feb 10 Apr 10 May 10 Aug 10 Sep 10 Feb 11 Apr 11 May 11 Jun 10 Jul 10 Nov 09 Dec 09 Jan 10 Mar 10 Nov 10 Dec 10 Jan 11 Mar 11Birchmount 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
  11. 11. 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 0.01 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=0Analysis 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
  12. 12. 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. 0.006TargetOntario Average - 0.00, lower value is desired. 0.004 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
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