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CMHA TORONTO QUALITY PERFORMANCE REPORT

Balanced Scorecard and Program Scorecard

Reporting Period: Q4- 2011-12

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PURPOSE:

To provide the Board with the first report of our efforts in strategic planning using the Balanced Scorecard (BSC)

as a management tool.

RECOMMENDATIONS

That the Board receives the report for information and discusses the performance measures

REASONS FOR RECOMMENDATIONS

In March 2010 the Strategic Plan for 2010-2013 was approved by the Board with a stipulation that quantifiable performance

metrics were needed. The report includes both organizational and programs scorecards result for the new strategic plan.

Additional measures and data may be added to future reports as we improve collection processes and systems throughout

201/13. It is also important to note that the performance report and associate measures will mature and evolve over time.

Performance thresholds may also be adjusted to reflect agency priorities and new information.

REPORT ELEMENTS

The report shows results for 39 measures measured at the organizational level, some of which are reported annually, no

immediate data. This report also includes a program level scorecard with 25 measures.

MEASURE STATUS

The status of each measure is indicated in the attached scorecards as:

● Green – equal or better than target

● Yellow – moving towards target

● Blue – in development/on track

● Red – level is below target

The summary scorecard is followed by a shortfall analysis sheet. For each of these measures, we provide explanations of why the

shortfall occurred and descriptions of resolution strategies being employed to improve performance.

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Legend Color Decision Leadership Action

Green ▲ Equal or better than target Reinforce

Yellow ► Moving towards target Stay the course

Blue ► In development/on track Continue monitoring

Red ▼ Level is below target Improvement required

n.a. Not tracked during this period

KPI Key Performance Indicator Maintain a close watch on this

Q 1 = April - June Q 2 = July - September Q 3 = October - December Q 4 = January - March

Perspective Finance

Goal Ensure sufficient resources to achieve the mission and strategic directions

Objectives # Measure Target Q1 Q2 Q3 Q4 Status

(green,

yellow,

red)

Comments

Continue prudent

fiscal management 1 % variance of net surplus vs budget

<.5%

+.7% +.7% +6

%

+.1

%

KPI

▲

A positive number indicates

that we are managing with

our available resources

2 % variance of investment returns actual vs

budget

<2%

-2.3% -5.2% -

2.3

%

-

1.8

%

▼ The global economy

negatively affected

investment returns for all managed balanced funds.

3 Amount of reserve funds Minimum $2

million

$3.5 million

$3.2 million

3.3m

3.3m

▲

Develop and

implementing a

new fundraising

strategy

4 Written/revised fund raising strategy

completed

By March

31/2011

- complet

ed

- -

5 % of implemented recommendations in the

strategy tbd - - - - ► Quarterly (Deferred to 2012/13

budget for board approval

6 % net growth in supplementary fundraising tbd - - - - ► Quarterly (Deferred to 2012/13

budget for board approval)

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Perspective Client and Community

Goal Meet client/community needs and foster inclusion

Objectives Measure Target Q1 Q2 Q3 Q4 Status

(green,

yellow,

red)

Comments

Continue advocacy

and system leadership

7 # of leaderships/policy activities involved in at the

provincial, national and LHIN levels

n.a.

- 71

- 45

Reductions reflect

adjustment in priorities

8 # of clients that are involved in advocacy activities n.a - 103

- 82

► This project is in its first

year of implementation

Promote mental health

& understanding of

mental illness

9 # of mental health promotion, workshops, presentations

offered within the last year

100

- 139 97 87 ▲ Annually reported

10 % of staff trained in Applied Suicide Intervention Skills

Training (ASIST)

100% 33% 94.3% 95.5% 99.19

% ▲

Implement diversity

and equity plan

11 % of programs that completed the development of their

Diversity & Equity work-plans

100%

- 100% - - ▲ Year 1 target only. This

represents clinical

programs only

12 % of staff participated in workshops

80%

- - - 65% ▼ Annually reported

13 % of programs that have implemented 50% or more of

their Diversity& Equity work-plans

90% - - - 90% Annually reported

14 % of programs that develop their 2nd diversity work plan

100% - - - - Year 3 indicator.

Annually reported and

only applies to direct

service teams

Develop and embed

consumer

participation

strategies

15 % of programs that implemented their CPI work-plans

80%

- - - 90.7

% ▲ Annually reported

16 Written Consumer Bill of Rights Completed

document Compl

eted

- - ▲

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Perspective

Internal Processes

Goal Develop and provide recovery based integrated services

Objective # Measure Target Q1 Q2 Q3 Q4 Status

(green,

yellow,

red)

Comments

Continue service in

high need areas

aligned with our

core competence

17 % of functional centres that fall within the LHIN

corridor for number of clients served

100%

- 100% 100% 81.8% KPI

▼

Two programs did not achieved

their target

18 % of functional centres that fall within the LHIN

corridor for number of client visits

100%

- 100% 100% 100% ▲

KPI

All quarterly targets have been

achieved

19 % of programs at 90% capacity

100%

90.7% 90.9% 83.3% 90.9% ▼ 10 of 11 programs met capacity

targets

20 % of staff that received recovery training 80% 100%

- - 100% ▲

21 % of clients satisfied with service received

80%

- 87% - - KPI Annually reported

Target has been exceeded

Develop chronic

disease prevention

and management

options

22 % of clients surveyed for having a chronic disease 50%

- - - - Delayed start due to other

training priorities.

23 % of clients in EI and ACT who have been screened for

metabolic syndrome

80% - 72% 80% ▲

24 % of staff that received training in chronic disease

management

50%

- 7% - - ▼ Delayed program start due to

other organizational training

25 # of clients receiving direct services that are involved in

prevention activities (footcare, walking group, SMW,

Chronic Disease Management (CDM) training, diabetes

screening)

40% - - - 55% Year two indicator only.

Develop concurrent

disorder capacity

26 % of clients screened with an approved instrument

80%

- - - - Target already achieved (Year 1

indicator only)

27 % of clients screened as having concurrent disorders

receiving integrated care

tbd - - - - To be determined

28 % of staff that received concurrent disorder training 80%

- 88.7% - 88.7 ▲

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Perspective Learning and Growth

Goal Develop a quality culture

Objective # Measure Target Q1 Q2 Q3 Q4 Status

(green,

yellow,

red)

Comments

Ensure that

CMHA remains a great place to

work

29 % of staff satisfied in their current job

90%

- 87% - - KPI ▼ Annually reported

Based on recent

accreditation survey results

30 % of exiting staff that voiced satisfaction/

dissatisfaction with the agency - - 100% 100% 100% ▲ Results for satisfaction

only.

31 # of paid sick days per staff 7 - 2.52 2.76 2.72 ▲

Develop Quality

& Safety Improvement

32 % of formal complaints resolved as per policy

timeline

n/a

- 100% - 100% ▲ This applies to service

complaints only. Sixteen

( 16) compliments for staff

were formally received

33 % team conducting monthly safety huddles 100% - 90% 90% 93% ▼

Only one non-clinical

program has not reported

data.

34 % of staff who received safety training 100% 93.4% 93.4% 98% ▼ 4.6% increase over the last

period

35 # WSIB Claims 4 - 4 0 1

Develop a

Learning culture

36 Balanced scorecard developed Completed

document

- - - - Document completed

37 # of successful student placement within the last year 7 - 9 9 8 ▲

Achieve

accreditation 38 % of ROP compliance (24/26) 100% 82% 92% 92% 100% ▲

KPI

Target is on track as

projected

39 QMENTUM certification – 24 months n/a - - - Achieved ▲ Accreditation status

achieved

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Program Scorecard Q4, (Jan – March 31, 2012)

Program Scorecard

January – March31, 2012 Color Decision Leadership Action

Green ▲ Equal or better than target Reinforce

Yellow ► Moving towards target Stay the course

Blue ► In development/on track Continue monitoring

Red ▼ Level is below target Improvement required

n.a. Not tracked during this period

Program KPI (not included) Key Performance Indicator Maintain a close watch on this KPI = Key Performance Indicator

Q 1 = April - June Q 2 = July - September Q 3 = October - December Q 4 = January - March

Results

Program Key Measures Baseline Target Q1 Q2 Q3 Q4 Reporting

Schedule

Accreditation

Quality

Dimensions

ACTT % of clients that have had

metabolic monitoring

within the last year

n/a 65% n/a n/a n/a 80% Annually Effectiveness

% of clients with no

mental health

hospitalization within the last year (admissions

n/a 75% 90% 84% 82% 79% Quarterly

Case % of new clients receiving TE Nil 60% 100% 100% 100% 100% Quarterly Accessibility

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Management ( TE-CM,TW-

CM,CTO,MHJ-

Prevention,, RAP

TE,TW,MHJCM,RAP

TE,TW,MHJCM,RAP

service within intake benchmark

( separate targets for each

team based on model of service)

TW 40% 60% 100% 100% 100% 100% Quarterly Accessibility

CTO 69% 75% 94% 89% 88% 90% Quarterly Accessibility

MHJCM 60% 80% 40% 64% n/a n/a Quarterly Accessibility

MHJPP 98% 100% 100% 100%

% of clients participating in meaningful activities

40% 50% n/a 63.5% n/a Semi-annually

Client Centred- Services

% of clients gainfully employed

17.2% 25% n/a 15.7% n/a Yr2 Effectiveness

CTO % of clients with no mental health

hospitalizations within the

last year

87% 90% 92% 91% 89% 85% Quarterly Effectiveness

Court

Support

% of clients that have

been diverted within the

last year

68% 75% n/a n/a n/a 77% Annually Effectiveness

# of clients that were

successfully linked to

services

61% 65% n/a n/a n/a 71% Annually Continuity of

Services

TCM 5% increase in MCAS

Scores

53% 58% n/a 100% n/a Semi-

annually

Safety

Reduction in the number

of admission (hospitalization)

4 (clients) 3 (clients) n/a 2

Clients

n/a Semi-

annually

Safety

TRHP 7% increase in client

satisfaction with program

activities

63% 70% n/a 100% n/a Semi-

annually

Client-Centered

Services

5% increase in MCAS

Scores

53% 58% n/a 90% n/a Semi-

annually

Safety

# of clients that were

successfully linked to services

61% 65% n/a n/a n/a Annually Continuity of

Services

Intake & 10% increase in file audit 50% 60% 80% 80% 80% 80% Quarterly Safety

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Referral each session

Housing % of clients with 24mths

tenure

n/a 80%

participation rate

80% 75% 71% 73% Quarterly Population Focus

20% reduction in evictions 19 (#) 20%

67%

42% 21 Quarterly

SRC & What

Next

20% increase in the

number of participants

attending recovery based

education/groups

60% 80%

Participation

rate

82% 97.6% 100% 100% Quarterly Client-Centred

EI & TYP 3% increase in the number

of clients in school, working or volunteering

77% 80% 77% 90% 100% 100% Quarterly Accessibility

60% increase in the number of clients who

receive first contact with

program within 72 hours

of referral

20% 80% 100% 100% 100% 100% Quarterly Accessibility

SafeBed Decrease the turnaround

time for SB units

2 days 4hrs 1.24hr 1.24hr 1.65 2.11hr Quarterly Effectiveness

% of time that SB met the

4hrs

75% 85% 100% 100% 98.5 97% Quarterly Effectiveness

Increase the % of clients

that were successfully linked to Case

Management Services

70% 80% 100% 95.6% 100 100% Quarterly Effectiveness

% of time that SB met the

72hrs target for referring

clients to Case

Management Services

60% 75% 73% 71% 76% 84% Quarterly Effectiveness

Employment 8% increase in clients

accessing available retention days past

probationary period

67% 75% 73% 94% 85 Quarterly Effectiveness

100% increase in youth

referral to employment

services

50% 100% 34% 100% 100 Quarterly Effectiveness

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SHORTFALL ANALYSIS – Organizational Scorecard

Shortfall Analysis Q4

Shortfall Analysis 1

Objective : Ensure sufficient resources to achieve the mission and strategic directions

Measure: # 2

Target: Result:

% variance of investment returns actual vs budget

<2% -1.8 % ▼

Cause(s) ▪ Investment returns for all managed balanced funds have been

negative due to slowdown in global economy and the Euro

debt crisis.

Resolution Investment manager has shifted asset mix away from European and

global markets

CMHA is tr Transferring monthly dividends from the balanced fund to a money

market fund, thereby moving asset mix to more conservative position

Our investment policy has a medium to long-term timeframe. Although

these short-term losses are painful, long-term strategy for a balanced portfolio should benefit over time.

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Shortfall Analysis 2

Objective : Implement diversity and equity plan

Measure: # 12

Target: Result:

% of staff who received safety training 80% 65% ▼

Cause(s) ▪ Fewer workshops offered and lower in staff participation

(workshops not filled to capacity as in previous years) because of

accreditation-related work-load in time of constraints

Resolution 9-10 workshops will be offered in 2012-13 to ensure there is

enough space for staff to attend.

Communication and coordination with managers to ensure each

training is filled to capacity will take place.

Shortfall Analysis 3

Objective :

Continue service in high need areas aligned with our core competence

Measure: # 17

Target: Result:

% of functional centres that fall within the

LHIN corridor for number of clients served 100% 81.8% ▼

Cause(s) ▪ ?

Resolution ▪ ?

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Shortfall Analysis 4

Objective : Continue service in high need areas aligned with our core competence

Measure: # 19

Target: Result:

% of programs at 90% capacity 100% 90.9 % ▼

Cause(s)

▪ Staff transition into leadership positions, turnover and maternity

coverage. This required existing case managers to cover caseload until

new staff could be hired and trained

Resolution Review staff transition process…..

Set monthly targets for new staff to increase staff caseloads to

meet/exceed program target of 90%

Shortfall Analysis 5

Objective : Develop chronic disease prevention and management options

Measure: # 24

Target: Result:

% of staff that received training in

chronic disease management

50% 7% ▼

Cause(s) ▪ Delayed program start due to staffing & resource issues

Resolution Develop a revised implementation plan

Secure funding from the LHIN

Hire required staff

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Shortfall Analysis 6

Objective : Ensure that CMHA remains a great place to work

Measure: # 29

Target: Result:

% of staff satisfied in their current

job

90% 87% ▼

Causes ▪ May be reflective of increase workload and increase stress

on the job as indicated in the accreditation work-life balance

survey. (N = 189 (down 5% from last year 2010).

▪ Wage restriction legislation

▪ Implementation of new MOHLTC initiatives

Resolution HR committee to review results/root cause

Continued dialogue with staff and managers

▪

Shortfall Analysis 7

Objective : Develop Quality & Safety Improvement

Measure: # 33

Target: Result:

% team conducting monthly safety

huddles

100% 93% ▼

Cause(s) ▪ Non-clinical programs not actively reporting that they have

conducted safety huddles

Resolution Improve communication with non-clinical teams

Create an e-reporting form.

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Shortfall Analysis 8

Objective : Develop Quality & Safety Improvement

Measure: # 34

Target: Result:

% of staff who received safety training 100% 98% ▼

Cause(s) ▪ Target has not been reached due to normal scheduling issues

Resolution Develop alternative methods for training delivery

Program Shortfall Analysis – Q4

Shortfall Analysis A

Program: CTO Objective: To Increase Program Effectiveness

Measure:

Target: Result:

% of clients with no mental health

hospitalizations within the last year 90% 85% ▼

Cause(s) ▪

Resolution

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Shortfall Analysis B

Program: Housing

Measure:

Target: Result:

% of clients with 24mths tenure 80% 73% ▼

Cause(s) 60% of discharges for long term incarcerations, hospitalizations and

death

Resolution

Shortfall Analysis C

Program: Housing

Measure:

Target: Result:

20% reduction in evictions 15 21 ▼

Cause(s) 52% for safety reasons and or long term incarcerations

Resolution

Shortfall Analysis D

Program: CTO

Measure:

Target: Result:

% of clients with no mental health

hospitalizations within the last year 87% 85% ▼

Cause(s)

Resolution

Definitions

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Terms Explanations

Balanced Scorecard An integrated framework for describing strategy through the use of linked performance measures in four, balanced

perspectives ‐ Financial, Customer, Internal Process, and Employee Learning and Growth. The Balanced Scorecard acts

as a measurement system, strategic management system, and communication tool.

Financial Perspective One of the four standard perspectives used with the Balanced Scorecard. Financial measures inform an organization whether strategy execution, is leading to improved bottom line results.

Client/Community Perspective One of the four standard perspectives used with the Balanced Scorecard. Measures are developed based on the answer

to two fundamental questions ‐ who are our target customers and what is our value proposition in serving them?

Internal Process Perspective One of the four standard perspectives used with the Balanced Scorecard. Measures in this perspective are used to

monitor the effectiveness of key processes the organization must excel at in order to continue adding value for stakeholders.

Learning and Growth Perspective One of the four standard perspectives used with the Balanced Scorecard. Measures in this perspective are often considered "enablers" of measures appearing in the other three perspectives.

Measure A standard used to evaluate and communicate performance against expected results.

Objective A concise statement describing the specific things an organization must do well in order to execute its strategy.

Perspective In Balanced Scorecard vernacular perspective refers to a category of performance measures

Target Represents the desired result of a performance measure. Metabolic syndrome Metabolic syndrome is the name for a group of risk factors linked to overweight and obesity that increase your chance for heart

disease and other health problems such as diabetes and stroke. The term “metabolic” refers to the biochemical processes involved in

the body's normal functioning. ...

www1.cardiotabs.com/glossary.asp

KPI Key Performance Indicator