tsh corporate scorecard - 2010 11 q3 c

Our 1st Priority (to 30-Jun-11) Indicator

1st Qtr Reported

Current Value

Previous Value Target

Current Status

Risk Rating* Page

Patient satisfaction - Overall Impression:● ED: Would you recommend TSH for Emergency Department services? 49.1 49.7 50 R H 2

● IP: Would you recommend TSH for an In-patient stay? 67.2 61.9 73 Y n/a 2

Percentage of publicly reported patient safety indicators meeting the provincial target (see addendum) 63% 58% 100% Y n/a 4

Number of incident reports completed (medication and non-medication) 743 730 490 G n/a 6

Hospital Standardized Mortality Ratio (HSMR) 74 84 100 G n/a 7

Rate of hand hygiene compliance before initial patient/patient environment contact 85% 92% 90% R 8

Rate of hand hygiene compliance after patient/patient environment contact 89% 96% 90% R 8

Percentage of staff and physicians educated in Mission, Vision and Values defined behaviours Q4Staff and Physician satisfaction:

● Employee Satisfaction survey results (Commitment composite score) 50.9% 37.5% 59% Y n/a 9

● Physician Satisfaction survey results (Commitment composite score) 42.7% 28.8% 43% Y n/a 10

Percentage of defined Model of Care positions transitioned 100% 100% G n/a 11

Performance evaluations● Percentage of leaders with completed performance evaluations Q3 100%

● Percentage of Medical Directors with completed performance evaluations Q3 80% 100% Y n/a 12

● Percentage of non-union staff with completed performance evaluations Q3 100%

● Percentage of unionized staff with completed performance evaluations Q3 50%

Percentage of leaders educated in LEAN methodology Q4HIT indicator #17, Percentage of equipment cost to total expense 5.2% 5.4% 5.9% R M 13

Number of standardized order sets used Q1 2011/12

Percentage of Clinical Service Plan (CSP) recommendations implemented Q4 100%

Percentage of PMO project milestones met 47% 96% 80% R M 14

Percentage of Programs and Departments with performance indicator scorecards and action plans that are posted and updated quarterly on the Intranet 75% 75% 100% Y n/a 15

Total margin 0.30% -0.31% 0% G n/a 16

Percentage of accountability agreement indicators achieved 88% 88% 80% G n/a 17

* Risk rating only completed for indicators that are not meeting the target and have not improved over the prior reporting period

Current Status Legend:Red = Performance indicator has not met the target for the current reporting period, and has not improved over the prior reporting periodYellow = Performance is below the target, however it has improved over the previous reporting periodGreen = Performance indicator has met or exceeded or is not statistically different than the performance target for the current reporting period

M = Medium reputational, financial or operational riskH = High reputational, financial or operational risk

Risk Rating LegendL = Low reputational, financial or operational risk

The Scarborough HospitalCorporate Balanced Scorecard

Q3 2010/11

Values: I ntegrity, C ompassion, A ccountability, R espect, E xcellence

Our Programs, Plans and Partners: As a unified organization, lead the development of a coordinated plan for the provision of care for all of Scarborough.

Mission: To provide an outstanding care experience that meets the unique needs of each and every patient.

Our Performance: Create an accountable, high performing organization that delivers measureable results.

Vision: To be recognized as Canada’s leader in providing the best healthcare for a global community.

Our People: Be the first choice for motivated, talented people who are inspired to deliver and support excellent care in a diverse environment.

Strategic DirectionOur Patients: Create an environment of patient safety that exceeds our patients' highest expectations and delivers care that is patient and family driven.

Service Excellence: To

provide respectful and responsive service to our

patients and each other.

Page Addendum

IndicatorCurrent Value

Previous Value Target

Current Status Risk Rating* Page

Our Patients:

Emergency Department Wait Time for High Acuity Visits - General Campus 19:35 15:12 8:00 R H A1Emergency Department Wait Time for High Acuity Visits - Birchmount Campus 22:51 12:12 8:00 R H A2Emergency Department Wait Time for Low Acuity Visits - General Campus 5:31 4:48 4:00 R H A3Emergency Department Wait Time for Low Acuity Visits - Birchmount Campus 4:57 4:30 4:00 R H A4Percent of CTAS 1&2 meeting 8 hour target 66% 71% 90% R H A5Percent of CTAS 3 meeting 6 hour target 66% 73% 90% R H A6Percent of CTAS 4&5 meeting 4 hour target 79% 84% 90% R H A7Rate of Hospital Acquired C. difficile Associated Diarrhea 0.32 0.22 0.28 R M A8Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia 0.00 0.00 0.02 G n/a A9Rate of Hospital Acquired Vancomycin Resistant Enterococcus (VRE) Bacteraemia 0.00 0.00 0.00 G n/a A10Rate of Central Line Infection (CLI) 1.48 0.61 0.75 R A11Rate of Ventilator Associated Pneumonia (VAP) 0.00 0.76 1.46 G n/a A12Rate of Timely Administration of Prophylactic Antibiotics - Primary Hip & Knee 98.0% 97.6% 96.1% G n/a A13Wait Time - General Surgery 82 67 182 G n/a A14Wait Time - Cancer Surgery 65 54 84 G n/a A15Wait Time - Cataract Surgery 123 223 182 G n/a A16Wait Time - Total Hip Replacement 123 151 182 G n/a A17Wait time - Total Knee Replacement 106 153 182 G n/a A18Wait Time - CT 20 23 28 G n/a A19Wait Time - MRI 99 116 28 Y M A20

* Risk rating only completed for indicators that are not meeting the target and have not improved over the prior reporting period

Status Legend: Risk Rating 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

Values: I ntegrity, C ompassion, A ccountability, R espect, E xcellence

Vision: To be recognized as Canada s leader in providing the best healthcare for a global community.Mission: To provide an outstanding care experience that meets the unique needs of each and every patient.

Strategic Direction


Publicly Reported Patient Safety Indicators

Page A1

Performance Measurement Summary

Action PlanInitiative Lead Date Initiated Status

Schedule to Demand M. Tang Jan-11 PendingED PIP Kaizen Events S. Gilbert Aug-10 In progressNP LTC B. Bickle Jun-10 OngoingPerformance Huddles Leadership Team Jun-10 Ongoing

Ongoing

Rounding for Outcomes D. Edman Jun-10 OngoingSchedule to Demand D. Edman Jun-10 Completed

J. Phan Sep-09 Ongoing

Virtual CDU implemented Dr T. Chan Apr-10 OngoingCharge Nurse and Triage RN Education T. Reardon Mar-10

Time Frame Q4 2010/11 (Jan)Source MOHLTC Wait Times Website / NACRS

There are challenges related to discharge processes, bed turnover times, and bed availability. As a result of ED PIP, white boards, discharge huddles, patient education and discharge processes have improved on participating units. Spreading the concept to other units is underway. Changing the philosophy to shared accountability for patients is spreading.

GEM D. Driver Oct-09 OngoingED PIP initiated

DefinitionThis indicator reports the 90th Percentile Wait time for all ED Admits with CTAS 1-5 and NonAdmits with CTAS 1-3.

CHART PLACEHOLDER

SignificanceThis indicator is associated with efficiency within the ED and within the hospital, as well as with ED patient satisfaction.

TargetMOHLTC Target - 8:00, lower value is desired.

Risk RatingHigh - There will be reputational impact of dissatisfied patients waiting in Emergency Department and potential financial risk of losing Pay-for-Results funding.

Analysis

Strategic Direction Our Patients



Indicator Emergency Department Wait Time for High Acuity Visits - General Campus

15:5

4, n

=805

1

15:3

1, n

=793

8

15:3

2, n

=851

2

16:4

7, n

=851

7

15:4

8, n

=888

3

13:1

2, n

=974

7

15:1

2, n

=107

27

19:3

5, n

=351

8

0:00

2:00

4:00

6:00

8:00

10:00

12:00

14:00

16:00

18:00

20:00

22:00

General Campus Target

Page A2


Action Plan

Schedule to Demand M. Tang Jan-11 Pending

Ongoing

Performance Huddles Leadership Team Jun-10 OngoingRounding for Outcomes M. Tang Jun-10 Ongoing

S. Vellani Jun-09 Ongoing

ED PIP initiated N. Alli, T. Osgood May-10 In progressVirtual CDU implemented Dr T. Chan Apr-10

OngoingLaboratory Technologists G. Bajwa Sep-09 Ongoing

Charge Nurse and Triage RN Education L. Vanden Kroonenberg Mar-10 OngoingNP LTC

Initiative Lead Date Initiated

GEM E. Laine Jun-09


Status

There are challenges related to specialty consultations and Diagnostic Imaging procedures.

DefinitionThis indicator reports the 90th Percentile Wait time for all ED Admits with CTAS 1-5 and NonAdmits with CTAS 1-3.

CHART PLACEHOLDER




Analysis




Indicator Emergency Department Wait Time for High Acuity Visits - Birchmount Campus

17:0

2, n

=638

7

15:3

0, n

=632

5

16:4

5, n

=656

1

16:3

1, n

=667

3

14:0

6, n

=666

8

13:3

6, n

=681

2

12:1

2, n

=716

6

22:5

1, n

=251

9

0:00

2:00

4:00

6:00

8:00

10:00

12:00

14:00

16:00

18:00

20:00

22:00

0:00

2:00

Birchmount Campus Target

Page A3


Action Plan

Ongoing

ED Staff Mar-10 In progress

Kaizen Events S. Gilbert Aug-10 In progressPerformance Huddles Leadership Team Jun-10

OngoingRPN Role D. Edman Jun-09 Ongoing

Rounding for Outcomes D. Edman Jun-10 OngoingSee and Treat Model of Care


ED PIP initiated J. Phan, N. Velosos Sep-09


Status

There are challenges related to flow of patient treatment between major and minor cases.

DefinitionThis indicator reports the 90th Percentile Wait time for all NonAdmit with CTAS 4-5 visits.

CHART PLACEHOLDER




Analysis




Indicator Emergency Department Wait Time for Low Acuity Visits - General Campus

06:3

7, n

=522

0

05:3

7, n

=547

7

06:0

7, n

=532

5

05:5

4, n

=448

7

05:4

2, n

=477

9

05:1

2, n

=448

1

04:4

8, n

=371

3

05:3

1, n

=124

5

0:00

1:00

2:00

3:00

4:00

5:00

6:00

7:00

8:00

9:00

General Campus Target

Page A4


Action Plan

D. Edman Jun-10 Ongoing

See and Treat Model of Care ED Staff Aug-10 In progress

In progressRPN Role D. Edman Jun-09 Ongoing

Performance Huddles Leadership Team Jun-10 OngoingRounding for Outcomes


ED PIP initiated N. Alli, T. Osgood May-10


Status

There are challenges related to flow of patient treatment between major and minor cases.

DefinitionThis indicator reports the 90th Percentile Wait time for all NonAdmit with CTAS 4-5 visits.

CHART PLACEHOLDER




Analysis




Indicator Emergency Department Wait Time for Low Acuity Visits - Birchmount Campus

06:3

7, n

=390

5

05:3

7, n

=389

4

06:0

7, n

=381

1

05:5

4, n

=327

1

05:1

8, n

=398

0

05:0

0, n

=395

0

04:3

0, n

=397

3

04:5

7, n

=118

8

0:00

1:00

2:00

3:00

4:00

5:00

6:00

7:00

8:00

9:00

Birchmount Target

Page A5


Action Plan

Strategic Direction Our PatientsTime Frame Q4 2010/11 (Jan)



Indicator Percent of CTAS 1&2 meeting 8 hour target

Source MOHLTC Wait Times Website / NACRS

DefinitionThis indicator reports the percentage of ED patients with CTAS 1 and 2 who completed their visit (Registration to Leaving ED) within 8 hours.

CHART PLACEHOLDER

SignificanceTo ensure adequate patient access and flow within ED and hospital.

TargetMOHLTC Target - 90%, higher value is desired.


AnalysisThere are challenges related to specialty consultations and Diagnostic Imaging procedures. A Diagnostic Imaging Kaizen event is taking place to improve Diagnostic Imaging callbacks wait times.

Initiative Lead Date Initiated Status

GEM D. Driver Oct-09 OngoingED PIP initiated J. Phan Sep-09 Ongoing

Virtual CDU implemented Dr T. Chan Apr-10 OngoingCharge Nurse and Triage RN Education T. Reardon Mar-10 Ongoing

NP LTC B. Bickle

Schedule to Demand D. Edman Jun-10 CompletedRounding for Outcomes D. Edman Jun-10 OngoingPerformance Huddles Leadership Team Jun-10 Ongoing

ED PIP Kaizen Events S. Gilbert Aug-10 In progressJun-10 Ongoing

67%

, n=1

912

68%

, n=1

854

66%

, n=1

773

64%

, n=1

795

69%

, n=2

045

70%

, n=2

332

71%

, n=2

787

67%

, n=8

55

65%

, n=1

216

68%

, n=1

203

69%

, n=1

228

66%

, n=1

181

69%

, n=1

203

73%

, n=1

401

73%

, n=1

413

65%

, n=4

63

66%

, n=3

128

68%

, n=3

057

67%

, n=3

001

65%

, n=2

976

69%

, n=3

248

71%

, n=3

733

71%

, n=4

200

66%

, n=1

318

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

General Birchmount TSH Target

Page A6


Action Plan




Indicator Percent of CTAS 3 meeting 6 hour target


DefinitionThis indicator reports the percentage of ED patients with CTAS 3 who completed their visit (Registration to Leaving ED) within 6 hours.

CHART PLACEHOLDER




AnalysisThere are challenges related to specialty consultations and Diagnostic Imaging procedures. A Diagnostic Imaging Kaizen event is taking place to improve Diagnostic Imaging callbacks wait times.


GEM D. Driver Oct-09 OngoingED PIP initiated J. Phan Sep-09 Ongoing

Virtual CDU implemented Dr T. Chan Apr-10 OngoingCharge Nurse and Triage RN Education T. Reardon Mar-10 Ongoing

NP LTC B. Bickle

Schedule to Demand D. Edman Jun-10 CompletedRounding for Outcomes D. Edman Jun-10 OngoingPerformance Huddles Leadership Team Jun-10 Ongoing

ED PIP Kaizen Events S. Gilbert Aug-10 In progressJun-10 Ongoing

51%

, n=2

604

60%

, n=3

050

60%

, n=3

399

60%

, n=3

381

65%

, n=3

784

72%

, n=4

553

73%

, n=4

877

67%

, n=1

486

58%

, n=2

563

63%

, n=2

771

58%

, n=2

721

61%

, n=2

837

65%

, n=3

130

67%

, n=3

203

72%

, n=3

698

66%

, n=1

167

55%

, n=5

167

61%

, n=5

821

59%

, n=6

120

60%

, n=6

218

65%

, n=6

914

70%

, n=7

756

73%

, n=8

575

66%

, n=2

653

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Page A7


Action Plan




Indicator Percent of CTAS 4&5 meeting 4 hour target


DefinitionThis indicator reports the percentage of ED patients with CTAS 4 and 5 who completed their visit (Registration to Leaving ED) within 4 hours.

CHART PLACEHOLDER




AnalysisThere are challenges related to flow of patient treatment between major and minor cases.


ED-PIP initiated J. Phan, N. Velosos Sep-09 OngoingRPN Role D. Edman Jun-09 Ongoing

Rounding for Outcomes D. Edman Jun-10 OngoingSee and Treat Model of Care ED Staff Mar-10 In progress

Kaizen Events S. Gilbert Aug-10 In progressPerformance Huddles Leadership Team Jun-10 Ongoing

72%

, n=3

864

76%

, n=4

280

73%

, n=3

974

75%

, n=3

457

73%

, n=3

534

79%

, n=3

600

82%

, n=3

101

78%

, n=9

88

66%

, n=2

644

74%

, n=2

978

68%

, n=2

634

71%

, n=2

406

76%

, n=3

093

81%

, n=3

253

85%

, n=3

438

80%

, n=9

77

69%

, n=6

508

75%

, n=7

258

71%

, n=6

608

73%

, n=5

863

74%

, n=6

627

80%

, n=6

853

84%

, n=6

539

79%

, n=1

965

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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)


Page A8


Action Plan

In progress

"Vernacare" system for both campuses emphasizing safe disposable of wastes on units has been implemented E. Lipnicki Jun-10 Completed


Proposal being made for an antimicrobial stewardship program to help decrease the use of antibiotics associated with the development of C. difficile

IPAC/Pharmacy Feb-11

Time Frame March 2011Source Surveillance and Case Finding

StatusIncreased vigilance to IPAC guidelines around C. difficile management for both campuses and enviromental audits of units

E. Lipnicki Jan-11 Ongoing

There have been a few months of increased cases of C. difficile at the General Campus since February 2010. Rates have begun to decline with increased monitoring and vigilance of infection control practices in the inpatient areas. The Birchmount Campus remains below the Ontario Average.

Definition Overall Rate of hospital acquired C. difficile associated diarrhea. Rate is based on total number of inpatients/patients with confirmed infection per 1000 patient-days.

CHART PLACEHOLDER

SignificanceTo track hospital acquired C. difficile rates in order to identify and implement infection control measures to prevent nosocomial spread of C. difficile. While C. difficile does not usually present a big problem for reasonably healthy adults, it can be quite serious for those who are frail or have other health challenges.

TargetOntario Average - 0.28, lower value is desired.

Risk RatingMedium- Controlling the rate of infection is very important to TSH. The increase in the rate of infection may cause some financial and reputational risk to the organization.

Analysis




Indicator Rate of Hospital Acquired C. difficile Associated Diarrhea

0.11

, n=1

0.35

, n=3

0.12

, n=1

0.00

, n=0

0.36

, n=3

0.23

, n=2

0.24

, n=2

0.46

, n=4

0.37

, n=3

0.13

, n=1

0.13

, n=1 0.

26, n

=2

0.58

, n=5

0.58

, n=5

0.45

, n=4

0.53

, n=5

0.25

, n=2

0.45

, n=4

1.09

, n=9

0.46

, n=3

0.48

, n=3

0.00

, n=0

0.00

, n=0

0.51

, n=3

0.49

, n=3

0.16

, n=1

0.49

, n=3

0.00

, n=0

0.34

, n=2

0.00

, n=0

0.00

, n=0

0.33

, n=2

0.00

, n=0

0.00

, n=0

0.15

, n=1

0.17

, n=1

0.15

, n=1

0.34

, n=2

0.26

, n=4 0.

40, n

=6

0.07

, n=1

0.00

, n=0

0.43

, n=6

0.34

, n=5

0.20

, n=3

0.47

, n=7

0.22

, n=3

0.22

, n=3

0.07

, n=1

0.15

, n=2

0.47

, n=7

0.35

, n=5

0.26

, n=4 0.

38, n

=6

0.22

, n=3 0.32

, n=5

0.78

, n=1

1

-

0.20

0.40

0.60

0.80

1.00

1.20

Oct

09

Nov

09

Dec

09

Jan

10

Feb

10

Mar

10

Apr

10

May

10

Jun

10

Jul 1

0

Aug

10

Sep

10

Oct

10

Nov

10

Dec

10

Jan

11

Feb

11

Mar

11

Apr

11

General Campus Birchmount Campus

TSH Ontario Average per 1,000 patient-days

TSH Rolling 12-month Average

Page A9


Action Plan

Risk Ratingn/a

Begin universal screening for MRSA colonization on admission IPAC Dec-10 In progress

Both General Campus and Birchmount Campus remains below the Ontario Average.

Initiative Lead Date Initiated StatusContinue with MRSA surveillance protocols E. Lipnicki Jul-10 Ongoing

Time Frame Q4 2010/11 Source Surveillance and Case Finding

Definition Overall Rate of hospital acquired Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia. Rate is based on total number of inpatients/patients with confirmed infection per 1000 patient-days.

CHART PLACEHOLDER

SignificanceHigher MRSA colonization rates will lead to higher rates of blood stream infections with MRSA. Tracking hospital acquired MRSA Bacteraemia rates helps to identify the clinical significance of MRSA colonization. This will help identify a need for further strategies to prevent nosocomial spread of MRSA.

Analysis





Indicator Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia

0.11

, 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

0.06

, 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

0.01

0.02

0.03

0.04

0.05

0.06




Page A10


Action Plan

In progress

ICRT invited for third party review July 20, 2010- waiting for final recommendations E. Lipnicki Jul-10 Completed


Universal screening to be implemented to identify patients colonized with VRE on admission and thus reduce nosocomial spread IPAC Dec-10

Time Frame Q4 2010/11 Source Surveillance and Case Finding

StatusVRE colonization outbreak over July 2010. Continue with IPAC protocols and ICRT recommendations for surveillance and outbreak management policies

E. Lipnicki Apr-10 Completed July 2010

There have been no reportable cases of VRE bacteraemia despite increased numbers of VRE colonized patients since April 2010.

Definition Overall Rate of hospital acquired Vancomycin Resistant Enterococcus (VRE) bacteraemia. Rate is based on total number of inpatients/patients with confirmed infection per 1000 patient-days.

CHART PLACEHOLDER

SignificanceTo track hospital acquired VRE bacteraemia rates in order to identify and implement necessary prevention plans to reduce the risk of infection from spreading.


Risk Ratingn/a

Analysis




Indicator Rate of Hospital Acquired Vancomycin Resistant Enterococcus (VRE) Bacteraemia

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.000

0.002

0.004

0.006

0.008

0.010

0.012




Page A11


Action Plan

OngoingChlohexidine dressings to help prevent CLIs

H. Clasky, D. Rose, S. Cesta, R. Lovinsky

Apr-10 Completed


Ongoing monitoring of insertion and maintenance BundleH. Clasky, D. Rose, S. Cesta, R. Lovinsky

Apr-10

Time Frame Q4 2010/11Source Surveillance and Case Finding

Status

Interdisciplinary team meetings to standardize protocols at the Birchmount Campus including physician and nursing education

H. Clasky, D. Rose, S. Cesta, R. Lovinsky

Jan-10 Ongoing

There has been a marked improvement to the number of CLI cases at TSH in January 2011. CLI strategies to standardize processes across the campuses is showing improvements in the rates.

Definition Overall rate of hospital acquired Central Line Infection. Rate is based on total number of CLI incidents diagnosed after two days of Critical Care admission per 1000 patient days.

CHART PLACEHOLDER

SignificanceTo track hospital acquired CLI rates in order to identify and implement necessary prevention plans to reduce the risk of infection from spreading.

Target Ontario Average - 0.75, lower value is desired.

Risk Ratingn/a

Analysis




Indicator Rate of Central Line Infection (CLI)

1.14

, n=1

0.00

, n=0

4.98

, n=5

6.32

, n=6

0.00

, n=0

2.21

, n=2

0.00

, n=0

2.06

, n=3

0.00

, n=0

0.00

, n=0

1.87

, n=1

0.00

, n=0

2.36

, n=1

2.54

, n=1

1.88

, n=1

0.00

, n=00.

75, n

=1

0.00

, n=0

3.90

, n=6 4.58

, n=6

0.69

, n=1

2.31

, n=3

0.61

, n=1 1.

48, n

=3

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11




Page A12


Action Plan

Dr. Clasky, C. Shelton, S. Cesta, R. Lovinsky

Jan-11 In progress

There were no VAP cases identified at TSH in January 2011.


Time Frame Q4 2010/11Source Surveillance and Case Finding

Status

Continue monitoring compliance bundles (maintenance and insertion) J.MacIsasc Jan-11 In progress

Interdisciplinary meeting with Birchmount Critical Care team to ensure compliance with safer healthcare bundle. Development of unit based scorecard to track progress. Ensure standardization between campuses.

Definition Overall Rate of hospital acquired Ventilator Associated Pneumonia. Rate is based on total number of VAP incidents diagnosed after two days of Critical Care admission per 1000 patient days.

CHART PLACEHOLDER

SignificanceTo track hospital acquired VAP rates in order to identify and implement necessary prevention plans to reduce the risk of development of pneumonia in the ICU patient population.

Target Ontario Average - 1.46, lower value is desired.

Risk Ratingn/a

Analysis




Indicator Rate of Ventilator Associated Pneumonia (VAP)

1.76

, n=1

0.00

, n=0

1.31

, n=1

2.47

, n=2

0.00

, n=0

1.40

, n=1

1.14

, n=1

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

4.56

, n=2

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.97

, n=1

0.00

, n=0

0.78

, n=1

1.58

, n=2

1.63

, n=2

0.90

, n=1

0.76

, n=1

0.00

, n=0

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

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 CampusTSH Ontario Average per 1,000 patient-daysTSH Rolling 12-month Average

Page A13


Action Plan

Indicator Rate of Timely Administration of Prophylactic Antibiotics - Primary Hip & KneeStrategic Direction Our Patients

TargetOntario Average - 96.1%, higher value is desired.



Time Frame Q3 2010/11Source Medical Systems Management (OR System)

DefinitionSurgical site infections occur when harmful germs enter a patient’s body through the surgical site (any cut the surgeon makes in the skin to perform the operation). Ways to prevent surgical site infections is by giving patients antibiotics 0 to 60 minutes or 0 to 120 minutes (vancomycin antibiotic) before they undergo surgery.

CHART PLACEHOLDER

Significance Conducting post-surgical infection surveillance and measuring the application of prophylactic antibiotics can be useful to enhance safety and quality of care, and to prevent complications thereby decreasing morbidity and mortality rates.

Risk Ratingn/a

Analysis

Implement standard order sets to improve compliance Nurse Educators Sep-09 CompletedPCMs Apr-09 In progress

StatusEnsure compliance through audits

All surgeon's offices have pre-printed orders. Work continues on ensuring a good process for improvement on this indicator. The drop at Birchmount Campus was due to one case where the patient received the antibiotic outside the recommended time. This was because pre-op orders did not reference that Clindamychi must be given 60 minutes pre-op. This has now been rectified.


95.7

%, n

=178

99.2

%, n

=243

98.7

%, n

=231

99.1

%, n

=216

99.4

%, n

=155

97.3

%, n

=215

97.2

%, n

=205

95.9

%, n

=71

98.7

%, n

=74

100.

0%, n

=60

95.9

%, n

=70

98.2

%, n

=56

98.5

%, n

=64

100.

0%, n

=85

95.8

%, n

=249

99.1

%, n

=317

99.0

%, n

=291

98.3

%, n

=286

99.1

%, n

=211

97.6

%, n

=279

98.0

%, n

=290

0%

20%

40%

60%

80%

100%

120%

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 Avg.Target

Page A14


Action Plan

OngoingHire of two new General Surgeons TSH Senior team Dec-09 Completed

Allocate OR time to services with wait time cases N. Rahim Dec-10 Ongoing


Continue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Dec-10

Time Frame Q4 2010 (Jan-Feb)Source MOHLTC Wait Times Website / CCO IPort

Status

General Surgery is performing well against Ontario average and provincial target. Patients are seen in a timely manner.

DefinitionWait time is defined as the 90th percentile number of days between the date of decision to treat and the time the surgical procedure is performed.

CHART PLACEHOLDER

SignificanceA measure of access and efficiency for patients requiring these procedures.

TargetMOHLTC Target - 182, lower value is desired.

Risk Ratingn/a

Analysis




Indicator Wait Time - General Surgery

68, n

=279

84, n

=279

61, n

=387

67, n

=314

68, n

=475

75, n

=397

75, n

=415

87, n

=499

88, n

=524

83, n

=419

67, n

=457

82, n

=356

-

20

40

60

80

100

120

140

160

180

200

TSH Ontario Target

Page A15


Action Plan

OngoingContinue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Dec-10 OngoingInitiative Lead Date Initiated

Allocate OR time to services with wait time cases N. Rahim Dec-10


Status

Cancer Surgery is performing well against Ontario average and provincial target. Patients are seen in a timely manner.


CHART PLACEHOLDER



Risk Ratingn/a

Analysis




Indicator Wait Time - Cancer Surgery

43, n

=100

46, n

=159

60, n

=217

53, n

=234

50, n

=169

59, n

=192

74, n

=223

49, n

=221

57, n

=191

54, n

=173 65

, n=2

67

-

10

20

30

40

50

60

70

80

90

TSH Ontario Target

Page A16


Action Plan

Ensure data quality check and re-education of Ophthalmology office staff to understand how to use of Decision Affecting Readiness to Treat (DARTs) Option on patients Wait Time records

N. Rahim Jan-11 In progressAllocate OR time to the Ophthalmology surgeons with wait times exceeding the WTIS target of 182 days N. Rahim Oct-10 In progressAllocate OR time to services with wait time cases N. Rahim Dec-10 OngoingContinue to monitor the performance of surgeons, wait time and OR blocks utilization N. Rahim Dec-10 Ongoing

The wait time for cataract surgery has decreased between January to February 2011 below the provincial target. Previous wait times was due to the lack of funding from CE LHIN for 2010/11. Funded volumes have decreased for TSH by 315 cases compared to 2009/10. In Q4 the CE LHIN allocated additional 400 cataracts to assist TSH to bring down the 90th percentile for cataracts. The additional cataract volumes have already impacted January's wait time. Q4 wait times will also be lower than Q3 due to data clean-up efforts undertaken.




CHART PLACEHOLDERRisk Ratingn/a

Analysis

Status




Indicator Wait Time - Cataract SurgeryStrategic Direction Our Patients


157,

n=1

409

138,

n=1

423

145,

n=1

418

145,

n=1

453

150,

n=1

613

149,

n=1

325

155,

n=1

434

165,

n=1

134

197,

n=1

438

212,

n=1

368

223,

n=1

331

123,

n=1

242

-

50

100

150

200

250

TSH Ontario Target

Page A17


Action Plan

OngoingContinue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Oct-09 OngoingInitiative Lead Date Initiated



Status

Total Hip Replacement Surgery is performing well against Ontario average and provincial target. Patients are seen in a timely manner.


CHART PLACEHOLDER



Risk Ratingn/a

Analysis




Indicator Wait Time - Total Hip Replacement

171,

n=5

2

117,

n=4

3

145,

n=6

1

130,

n=5

0

146,

n=7

7

131,

n=6

4

108,

n=8

7

114,

n=6

2

116,

n=7

4

124,

n=5

7

151,

n=6

3

123,

n=4

3

-

50

100

150

200

250

TSH Ontario Target

Page A18


Action Plan

OngoingContinue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Oct-09 OngoingInitiative Lead Date Initiated



Status

Total Knee Replacement Surgery is performing well against Ontario average and provincial target. Patients are seen in a timely manner.


CHART PLACEHOLDER



Risk Ratingn/a

Analysis




Indicator Wait Time - Total Knee Replacement

192,

n=2

02

159,

n=1

81

145,

n=2

42

124,

n=2

21

117,

n=2

23

113,

n=2

02

114,

n=2

41

124,

n=2

36

124,

n=2

22

130,

n=1

59

153,

n=2

22

106,

n=1

44

-

50

100

150

200

250

TSH Ontario Target

Page A19


Action Plan

T. Jackson Sep-10 PendingIn progress

Wait time data entry training for booking clerks V. Winters Nov-09 CompletedNov-09

Review existing contrast media delivery policy and explore options for extending contrast appointments T. Jackson Sep-10 PendingApplication for second CT at General Campus in Satellite location; will decrease all Wait Times


WTIS data error resolution done on a monthly basis - indicates data entry errors - follow up with staff Charge clerks


Status

Reduction noted based on changes to scheduling patterns and improvement in data capture as a result of retraining of staff. There are longer waits for priority 3, as many requests involve the use of contrast media and these appointments are limited.

DefinitionWait time is defined as the 90th percentile number of days wait for CT diagnostic scan.

CHART PLACEHOLDER

SignificanceTrack the wait time indicators to ensure that we are meeting our MOHLTC commitments and meeting the needs of our patients.


Risk Ratingn/a

Analysis




Indicator Wait Time - CT

34, n

=509

1

41, n

=475

7

32, n

=503

0

38, n

=510

5

38, n

=507

7

39, n

=517

6

36, n

=538

7

29, n

=516

9

21, n

=551

0

23, n

=517

7

23, n

=560

5

20, n

=396

8

-

5

10

15

20

25

30

35

40

45

50

TSH Ontario Target

Page A20


Action Plan

Operating hours extended to 24hrs during weekdays for Q4 2010/11 S. Porter Jan-11 In progress

MRI PIP- LEAN process for identifying improvements in MRI throughput S. Porter Jun-10 In progressIn progress

Wait time data entry training for booking clerks V. Winters Nov-09 Completed

Second MRI application sent to CELHIN, LHIN approval moved to MOHLTC T. Jackson Jul-10 In progress


WTIS data error resolution done on a monthly basis - indicates data entry errors - follow up with staff Charge clerks Nov-09


Status

MOHLTC target for priority 4 cases is 28 days and the CELHIN has a target of 76.5 days. Currently exceeding both. Demand for services continues to outstrip available resources. Current MRI Process Improvement Project (PIP) process is reviewing scheduling process for efficiencies. TSH receieved funding from CELHIN in Q4 for 360 additional MRI hours in hopes of decreasing wait times.

DefinitionWait time is defined as the 90th percentile number of days wait for MRI diagnostic scan.

CHART PLACEHOLDER

SignificanceTrack the wait time indicators to ensure that we are meeting our MOHLTC commitments and meeting the needs of our patients.


Risk RatingMedium - delays can affect patient care. P4 are the lowest priority. Long waits can negatively impact reputation.

Analysis




Indicator Wait Time - MRI

61, n

=184

4

64, n

=163

5

79, n

=174

4 101,

n=1

718

99, n

=184

4

103,

n=1

895

118,

n=2

240

133,

n=2

121

109,

n=2

028

107,

n=2

085

116,

n=2

132

99, n

=195

4

-

20

40

60

80

100

120

140

TSH Ontario Target


Action Plan

Team Charter, the ED Team Charter defines the purpose of the team, how we all work together and what the expected outcomes will be:• Utilized to lay the foundation of expected team behaviours• Utilized to guide staff in their performance and interactions with patients

Nursing Leadership Team and ED staff

Sep-10 Ongoing

Hiring the right people for the team. The ED will recruit and retain professionals with the right level of knowledge, technical expertise and interpersonal skill.• Select new staff who will make a positive difference to our patients• Select staff who support our mission, vision and values

D. Edman and T. Reardon Sep-10 Ongoing

Patient satisfaction - Overall Impression (Emergency Department and In-patients)Our PatientsQ3 2010/11NRC Picker

Risk RatingHigh- Reputational, financial or operational risk.

DefinitionResponse to Overall Impression questions in NRC Picker survey administered to a sample of discharged Emergency Department patients and In-patients:- Emergency Department (ED): Would you recommend TSH for Emergency Department services?- Inpatients: Would you recommend TSH for an In-patient stay?


Indicator

Sep-10

SignificanceThis indicator is a measure of patient's overall impression of the quality of care received.

Time Frame

Analysis

Strategic Direction

Source

StatusDate InitiatedLeadInitiative

TSH Emergency Department satisfaction scores is below the target. TSH Inpatient satisfaction scores continue to be below other Greater Toronto Area hospitals. TSH has made positive changes such as Code of Conduct, and faster response time to patient complaint by Patient Relations department.

CHART PLACEHOLDER

TargetTSH target is 50 for ED and 73 for IP, higher value is desired. The target is based on GTA average.

QCIPA Reviews• QCIPA case reviews take place whenever an incident, near miss or adverse event occurs• Recommendations are shared with staff

ED Leadership Team Ongoing

36.4

n=1

51

41.5

n=1

35

46.8

n=1

54

48.3

n=1

43

44.3

n=2

12

49.7

n=1

93

49.1

n=1

16

60.4

n=3

59

62.6

n=3

42

59.3

n=3

27

60.9

n=3

22

59.4

n=3

30

61.9

n=3

18

67.2

n=2

71

0

20

40

60

80

100

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 Avg

Staff Education, all staff are giving an opportunity to enhance or increase their knowledge and skill:• Charge Nurse workshops• Triage Nurse workshops• Monthly inservicing on selected topics• Customer service education

S. Gilbert and L. Vanden Kroonenberg

Sep-10 Ongoing

Completed for General CampusSep-10

Sep-10D. Edman and N. Alli

D. Edman and T. ReardonPatient friendly waiting roomGeneral 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 process

Fast track RAZ patientsGeneral 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

Completed for Birchmount Campus




Indicator Percentage of publicly reported patient safety indicators meeting the provincial target (see addendum)

Completed

Time Frame

T. Jackson Sep-09 - Mar-10

Risk Ratingn/a

• There continues to be improvement in our high and low acuity scores at both the General and Birchmount campus compared to a year ago.• There have been an increase in cases of C. Diff at the General campus since Dec-10. Rates have begun to decline with increased monitoring and vigilence of infection control practices in the inpatient areas. The Birchmount campus remains below the Ontario average.• There has been a decrease in the number of CLI cases at the Birchmount campus. Overall, TSH remains below the Ontario average. Standardization of CLI strategies across the campuses will assist in decreasing CLI cases across TSH.• There has been some decrease in VAP cases identified at the General campus and Birchmount campus in the last quarter. Both campuses are now below the Ontario average.• SSI - Antibiotics Timing - Hip/Knee: Work continues on ensuring a good process for improvement on this indicator.

DefinitionPercentage of 19 publicly reported patient safety indicators that meet the provincial targets.

Meditech, NACRS, IPAC, MOHLTC Wait Times Public Website

CHART PLACEHOLDER

SignificanceProvides information on patient safety issues where the goal is to enhance patient safety in the hospital by reducing the risk factors. Monitoring these indicators in the hospital is a priority and is key to keeping patients safe.

TargetTSH Target - 100%, higher value is desired.

Analysis

Early cluster identification and interventions including unit terminal cleaning, use of vernacare system, re-enforcement/education on hand hygiene, cleaning of equipments between patients and prudent use of antibiotics

Our Patients

• TSH patients continue to receive timely access to care. TSH wait time for general surgery, hip/knee, CT is below the provincial average.• The wait time for MRI is above the Ontario average, however, the wait time has increased to 116 in Q3 2010/11.• The wait time for cataract surgery has increased in Q3 2010/11 above the provincial target. There is a lack of funding from CE LHIN for 2010/11. Funded volumes have decreased for TSH by 315 cases compared to 2009/10. Wait time for cataracts will continue to increase unless additional funding is received.

SourceQ3 2010/11

Strategic Direction

Dr. I. Daves, B. Westcott, IPAC Sep-09

Interdisciplinary meeting with Birchmount critical care team to ensure compliance with safer healthcare bundle. Development of unit based scorecard to track progress. Ensure standardization between campuses

Dr. Clasky, C. Shelton, S. Cesta, R. Lovinsky

Implement standard order sets to improve compliance Nurse Educators Sep-09

An additional 300 hours of wait time funding accepted from CE LHIN reallocation. Implementation of expanded hours of operation to commence Sep-09

Continue to monitor CLI and VAP bundle compliance in Intensive Care Unit

Jan-10

CompletedIPAC Sep-09 Ongoing

Ongoing

In progress

53%

, n=1

0

63%

, n=1

2

63%

, n=1

2

58%

, n=1

1

63%

, n=1

2

0%

20%

40%

60%

80%

100%

120%

Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11

% patient safety indicators meeting provincial targets Target

ICRT invited for third party review July 20, 2010 - waiting for final recommendations

Feb-10

Completed

Completed

May-10 – General Dec-10 – Birchmount

Jun-10

CompletedJul-10

Pending

E. Lipnicki

ED PIP

E. Lipnicki

Staffing demand for nursing and physicians. Master schedule for nursing staff to be implemented June 21, 2010

MRI PIP - LEAN process for identifying improvements in MRI throughput S. Porter

Pay for Performance (P4R) funding received for year III: Electronic Bed Board; Clinical Facilitator; Laboratory Technologists; See and Treat; Staff to Demand; Rapid Admissions Unit (RAU); LEAN; ED PIP extension

L. Crawford, A. MacKinnon, Dr. T. Chan

To be integrated into base – Sep-10

Apr-10 Completed

Mar-10

Feb-10

OngoingWith the addition of 3 General surgeons, access to care should further improve. Continue to monitor wait times and ensure TSH is meeting funded volumesContinue to deliver cataract surgery to funded volumes only. Funding for an additional 123 cases has been received. This volume has already been delivered. Additional finding of 375 cases requested from the CE LHIN

Pursue 2nd CT scanner to increase capacity: Not approved to commence procurement. Linked to achievement of agreed upon nuclear cardiology referral volumes, which have not yet been met

Feb-10

Jan-10

Increased vigilence to IPAC guidelines around C. Diff management for both campuses

Ongoing

Feb-10

L. Crawford, A. MacKinnon, J. Phan

VRE colonization outbreak over Jul-10. Continue with IPAC protocols and ICRT recommendations for surveillance and outbreak management policies

May-10Continue to work with the Antibiotic Stewardship Committee to ensure prudent use of antibiotics to lower and maintain rates below the provincial average

Feb-10

Investigate feasibility of extending contrast cases to off-hours: Not supported at this time

In progress

Ongoing

N. Rahim

N. Rahim

N. Rahim

IPAC

In progress

B. Westcott, Dr. H. Clasky, Dr. R. Lovinsky, IPAC

In progress

Ready for implementation

L. Crawford, A. MacKinnon, Dr. T. Chan

L. Crawford, A. MacKinnon, D. Edman, Dr. T. Chan

May-10 In progress

E. Lipnicki Jun-10

L. Crawford, A. MacKinnon, N. Veloso

T. Jackson

ED PIP commenced Apr-10 at the Birchmount campus. Value Stream Mapping (VSM) completed. Entering solution design stage with launch on May 26, 2010

L. Crawford,A. MacKinnon, N. Alli

Second MRI application sent to CE LHIN, LHIN approval moved to MOHLTC

Clinical Decision Unit (CDU)L. Crawford, Dr. T. ChanVirtual CDU

IPAC, Dr. R. Lovinsky

Review of "vernacare" system for both campuses emphasizing safe disposal of waste. 4 new vernacare units approved for Birchmount campus in 2010 capital plan

In progress

In progressOngoing

Jun-10Jul-10

Fall 2010

Continue with MRSA surveillance protocols E. Lipnicki

T. Jackson

RAU

ED Process Improvement Project (PIP) has re-designed the Rapid Assessment Zone (RAZ) for a team approach to see and treat

Continue with notification to pharmacy regarding patient’s with diarrhea, early use additional precautions on symptomatic patients until C. Diff is ruled out and standardization of cleaning protocols and products for both campuses

Continue to ensure compliance with SSI - Antibiotics Timing (Hip/Knee). Overall compliance rate is currently 99%

Re institution of the Antibiotic Stewardship Committee to ensure prudent use of antibiotics. Development of a corporate policy for cleaning and disinfecting shared equipments and separation of clean and soiled utility room. Plan for increase vernacare waste macerators

Ongoing

Sep-10 In progress

CLI Rates beginning to drop with subsequent months for the General campus. Continue to monitor progress and collaborative work as outlined below

Collaborate with IPAC, Critical Care, Diagnostic Imaging, IV resource and Physician team on type of line to be inserted, compliance with insertion and maintenance bundles. Focus on hand hygiene improvement, reinforce importance of aseptic line access, timely removal of central lines, educate Physicians on line removal, empower nurses to prompt line discontinuation, improve line documentation

B. Westcott, Dr. H. Clasky, Dr. R. Lovinsky, IPAC

Feb-11ED wait times may not be met due to influenza surge during Q3. Cataract surgery wait times down to below target after significant clean up of wait time data in surgeons' offices completed by TSH staff. Continue with additional cleaning of C-diff affected units and auditing of infection control practices on these units. Plans in the works for additional MRI scanner installation at Birchmount summer 2011. This will help reduce MRI wait time

Ongoing

Ongoing

IPAC Feb-10

Feb-10 Ongoing

In progress

In progress

E. Lipnicki

Ongoing

E. Lipnicki

Feb-10 CompletedT. Jackson

L. Crawford, Dr. T. Chan Mar-10Mar-10

In progressJul-10


Action Plan

TSH is currently meeting target in this quarter. The experience in Canadian and U.S. hospitals is that adverse events are underreported and it can be assumed that TSH is no different. Therefore, the objective is to increase incident reporting, as least in the short term.

CHART PLACEHOLDER


Indicator Number of incident reports completed (medication and non-medication)

DefinitionIncident reports are one mechanism to capture the occurence of an actual or potential adverse event in an organization (others include chart reviews, patient complaints, etc.). An online webbased system (S.A.F.E.) provided by RL Solutions is used at TSH to report patient, visitor and staff actual and potential adverse events as well as track follow-up actions for these events.

Our Patients

S.A.F.E. (rLSolutions)

Strategic DirectionQ4 2010/11 (projected based on Jan-Feb 2011)

Risk Ratingn/a

Analysis

SignificanceTo track trends in adverse events in order to identify and implement necessary improvement plans.

TargetTSH Target - 490, higher value is desired. The target for this indicator has been established as a 5% increase from the corresponding quarter in the previous fiscal year.

Time FrameSource

Monthly reports provided to each PSG director Performance & Decision Support Apr-10 OngoingStatusDate InitiatedLeadInitiative

Quality of Care Committee reviews critical incident reports at each meeting and tracks status of recommendations

C. Hendriks Oct-10 Ongoing

Risk Management making regular report on incident trends and critical incidents quarterly to MAC C. Hendriks Oct-10 Ongoing

403

467

576

521

626

705 73

0

743

0

100

200

300

400

500

600

700

800

Q1 Q2 Q3 Q4 (projected based on Jan-Feb 2011)

2009/10 2010/11 Target


Action Plan

Analysis

StatusDate InitiatedLead

CHART PLACEHOLDER

Initiative

The 2009/10 year-end TSH HSMR showed dramatic improvement with the publicly released value of 84. We now rank within the top 10 in the GTA and 4th amongst peer community hospitals.

Source

Hospital Standardized Mortality Ratio (HSMR)Our PatientsStrategic Direction


Indicator

The Canadian Institute for Health Information (CIHI)

Dr. S. Jackson Ongoing

Time Frame

The following initiatives are underway:• 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

DefinitionThe ratio of actual in-hospital deaths to the expected number of in-hospital deaths for conditions that account for 80% of in-patient mortality. Where a HSMR score of 100 represents the actual number of deaths equal to the expected number of deaths. A number above 100 indicates a higher than expected number of deaths and a number below 100 indicates a lower than expected number of deaths.

SignificanceThis is a global indicator for patient safety and the quality of care provided within a facility.

TargetTSH Target - 100, lower value is desired.

Risk Ratingn/a

2010/11 (Apr-Dec)

Feb-10

137

129

131

127

112

112

80

75

122

120

114

114

105

97

88

73

132

126

124

122

109

106

84

74

0

20

40

60

80

100

120

140

160

2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 (Apr-Dec)



Action Plan

Strategic Direction Our PatientsTime Frame Q4 2010/11


Indicator Rate of hand hygiene compliance

Source Surveillance and Case Finding

Definition The single most common way of transferring health care-associated infections (HAIs) in health care settings is on the hands of health care providers. Health care providers move from patient to patient and room to room while providing care and working in the patient environment. This movement provides many opportunities for the transmission of organisms on hands that can cause infections.

CHART PLACEHOLDER

SignificanceProper hand hygiene protects patients and providers and will reduce the spread of infections and the associated treatment costs, reduce hospital lengths of stay and readmissions, reduce wait times, and prevent deaths.

Target.Ontario Target - 90% Before and 90% After, higher value is desired.

Risk Ratingn/a

AnalysisDue to the lack of modified workers and the VRE issue, there were not enough audits done to report for Q3 at the General Campus. The data for the Birchmount Campus exceeds the target for After care.

Continue with the development of a unit based hand hygiene program overseen by IPAC N. Vankoosingh Jul-10 In progressInitiative Lead Date Initiated Status

90%

, n=8

20

97%

, n=8

79

94%

, n=2

334

98%

, n=2

430

81%

, n=3

40

90%

, n=3

84

98%

, n=6

44

99%

, n=6

55

90%

, n=1

715

94%

, n=1

818

90%

, n=4

63

96%

, n=4

91

93%

, n=1

464

98%

, n=1

534

92%

, n=4

049

96%

, n=4

248

85%

, n=8

03

89%

, n=8

75

0%

20%

40%

60%

80%

100%

120%

Before After Before After Before After

2008/09 2009/10 2010/11

General Campus Birchmount Campus TSH Target



Strategic Direction


Indicator Employee Satisfaction survey results (Commitment composite score)Our People2010/11Time Frame

Source

Violence in the Workplace- Organized polices; Code White, harassment, discrimination, code of conduct and violence in the workplace under one heading – Respect in The Workplace. Rollout of training on Bill 168 to be completed in June. Ongoing training through learning institiute

NRC Picker

CHART PLACEHOLDER

S. Rai-Lewis

S. Rai-Lewis

SignificanceTo track trends in employee satisfaction in order to identify and implement necessary improvement plans.

All Hospital Average commitment scores for employees is 59.4% and Physician All Hospital Average for commitment is 43.1%. EOS increased by 13.1% and POS by 13.9%. Although we did not meet the target of 55% ,our data clearly indicates a statistically significant positive trend in commitment. Addressing prioritized areas of improvement both at the Corporate and unit level will continue to positively impact commitment scores going forward.

S. Rai-Lewis

TargetOntario Average - 59% for 2010/11 and 55% for 2008/09, higher value is desired.

Risk Ratingn/a

Sep-10

DefinitionThe Employee Opinion Survey measures employee satisfaction on various scales. Employee Commitment composite score is shown on the scorecard. Scores are out of 100. Commitment score is composed of average scores from 5 questions: i) Organization is great to work for ii) Proud to say part of organization iii) My values/organization's values are similar iv) Organization inspires best in you v) Glad chose organization over others.

Analysis

Scheduled for Fall 2011

Completed

CompletedIntroduce Pulse Survey to measure engagement (quarterly snapshot) Fall 2011

Mar-10

Employee Opinion Survey to be administered every 2 years, next full survey will be September 2010

37.5

%, n

=160

6 50.9

%, n

=159

0

0%

10%

20%

30%

40%

50%

60%

2008/09 2010/11

Commitment Score Target


Action Plan

The development of Physician leadership award Apr-10Dr. S. Jackson

OngoingOngoingThe development of the The Clinical Services Plan

Dr. S. JacksonApr-10

Initiative

Strategic Direction

Development of robust communication with family physicians Dr. S. Jackson Apr-10Performance review taking into account values including code of conduct

The 2010 survey shows dramatic improvement as compared to 2008. The 2010 commitment score of 42.7 is now comparable to the hospital average.

2010/11

TargetOntario Average - 43% for 2010/11 and 45% for 2008/09, higher value is desired.

Risk Ratingn/a

OngoingDr. S. JacksonOngoing

StatusDate InitiatedLeadApr-10

Source NRC Picker

CHART PLACEHOLDER

SignificanceTo track trends in physician satisfaction in order to identify and implement necessary improvement plans.

DefinitionThe Physician Opinion Survey measures physician satisfaction on various scales. The physician commitment composite score is shown on the scorecard. Scores are out of 100. Commitment score is composed of average scores from 5 questions: i) Organization is great to work for ii) Proud to say part of organization iii) My values/organization's values are similar iv) Organization inspires best in you v) Glad chose organization over others.

Analysis

Time FrameOur People


Indicator Physician Satisfaction survey results (Commitment composite score)

28.8

%, n

=141

42.7

%, n

=151

0%

10%

20%

30%

40%

50%

60%

2008/09 2010/11

Commitment Score Target


Action Plan

Strategic Direction Our PeopleTime Frame 2010/11


Indicator Percentage of defined Model of Care positions transitioned

Source Internal Tracking

DefinitionPercentage of clinical resource staff (i.e. nurse educators and nurse clinician) who have transitioned and are functioning in the new Clinical Resource Leader role.

CHART PLACEHOLDER

SignificanceModel of Care positions supports excellent care and full scope of practice and enhances partnerships between practice and operations.

Target100%

Risk Ratingn/a

AnalysisAll positions have been transitioned and all are functioning in the role.

Transition of clinical resource staff to the new Clinical Resource Leader role R. Seidman-Carlson Apr-10 CompletedInitiative Lead Date Initiated Status

100%

, n=2

1

0%

20%

40%

60%

80%

100%

120%

2010/11

% positions transitioned Target


Action Plan

Strategic Direction Our PeopleTime Frame Q3 2010/11


Indicator Percentage of Medical Directors with completed performance evaluations

Source Internal Tracking

DefinitionPercentage of Medical Directors with completed annual performance evaluations. Percentage based on total number of Medical Directors in the hospital.

CHART PLACEHOLDER

SignificanceEmployee evaluation is important for development of staff and managers to be aware of employee development needs.

TargetInternal Target - 100%, higher value is desired.

Risk Ratingn/a

AnalysisPerformance evaluations are on track to be completed by the end of the fiscal year.

Initiative Lead Date Initiated StatusInitialization of Medical Directors performance and evaluations Dr. S. Jackson Apr-10 Ongoing

80%

, n=8

0%

20%

40%

60%

80%

100%

120%

Q3 2010/11

% Medical Directors with completed evaluation Target


Action Plan

In progress

HIT indicator #17, Percentage of equipment cost to total expenseOur Programs, Plans and Partners


IndicatorStrategic Direction

Lack of investment in equipment and technology may impact quality of care and performance. Equipment depreciation has declined due to delay in acquisition of new equipment (i.e. CTs).

CHART PLACEHOLDER

StatusDate Initiated

SignificanceTo track our investment in equipment and technology in comparison to our industry.

TargetLHIN Average - 5.9%, target value is desired.

Risk RatingMedium - Impact would be operational (i.e. quality).

Analysis

R. AnsteyLeadInitiative

2010/11 (Apr-Sept)Healthcare Indicator Tool (HIT)

DefinitionTotal equipment cost (including depreciation rental/lease and maintentance cost) as a percent of total hospital expense.

Time FrameSource

Expedite acquisition of major pieces of equipment included in 2010/11 Capital Plan Feb-11

6.2%

6.2%

5.6%

5.2% 5.

4%

5.2%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 (Apr-Sept)

% of equipment cost to total expense Target


Action Plan


Indicator Percentage of PMO project milestones metStrategic DirectionTime FrameSource

Our Programs, Plans, and PartnersQ3 2010/11Eclipse project management application

DefinitionA number of initiatives for the department have been agreed upon at the outset of the fiscal year. Each initiative has milestones that must be achieved. This measure represents all milestones achieved for all initiatives as a percentage.


Risk RatingMedium- Reputational, financial or operational risk.

Analysis

LeadInitiative

In Q3 2010/11, fourty-three milestones were being tracked by the PMO. In this quarter, 20 of 43 milestones have been met.

CHART PLACEHOLDER

StatusDate Initiated

SignificanceA measure of department performance, efficiency and planning.

J. Cox Ongoing

Inventory of task timelines being development to guide future project plans (e.g. RFP development and positng, contract negotiation, hardware procurement)

J. Cox Oct-10 Ongoing

Sep-10Monthly status reports required from each project manager to report on project status, met and missed milestone, project risksPMO Advisory Committee Coach assigned to each project to provide advice on Status Report content C. Flemming Sep-10 Ongoing

Largest proportion of missed milestones were presentation of Business Cases. These presentations are scheduled for March 7

C. Flemming Feb-11 Ongoing

PMO Lead reviewing all project milestones to ensure they meet the milestone definition and that there are sufficient milestones to track the project. Feedback provided to project managers

J. Cox Oct-10 Ongoing

94%

, n=1

5

96%

, n=2

2

47%

, n=2

0

0%

20%

40%

60%

80%

100%

120%

Q1 2010/11 Q2 2010/11 Q3 2010/11

% milestones achieved Target


Action Plan

Our Performance

CHART PLACEHOLDER

Lead


Risk Ratingn/a

Initiative Date Initiated

A schedule has been developed for VP/ED scorecard reporting at the weekly Senior Management Team (SMT) meeting. The Performance & Decision Support PDS consultant is responsible for building and maintaining scorecards for their respective PSGs on a quarterly basis. There are a total of 20 Scorecards (1 Corporate, 7 VP/ED, and 12 PSG/Depart.).


Indicator Percentage of Programs and Departments with performance indicator scorecards and action plans that are posted and updated quarterly on the Intranet

DefinitionA Corporate Scorecard (1) has been developed, along with scorecards for each VP/ED portfolio (7), PSG and clinical support department (12). This measure reflects whether the scorecards (including action plans) were published and posted on the SharePoint.

Q3 2010/11Time FrameSource

Strategic Direction

Pending

VP/ED Scorecard SMT presentation schedule established

Discuss QIP and VP/ED Scorecards at March SMT meeting C. Flemming Feb-11

Performance & Decision Support

Analysis

SignificanceRoutine uploading of scorecards will facilitate regular review of the indicators and transparency to the staff and other departments.

StatusCompleted

VP/ED Scorecards to be sent to PDS upon completion for publication on the PDS SharePoint site C. Flemming Aug-10 PendingC. Flemming Aug-10

85%

, n=1

7

75%

, n=1

5

75%

, n=1

5

0%

20%

40%

60%

80%

100%

120%

Q1 2010/11 Q2 2010/11 Q3 2010/11

% of posted scorecards Target


Action Plan

2010/11 (Apr-Jan)

DefinitionTotal margin is the percentage by which total revenues exceed or fall short of total expenses. A positive percent indicates an operating surplus position where a negative percent reflects an operating deficit position.

Time Frame


Indicator Total marginStrategic Direction Our Performance

Source Finance

SignificanceTo ensure the Hospital is operating in a balanced or surplus position.

TargetTSH Target - 0%, target value is desired.

Risk Ratingn/a

April to January result of 0.30% reflects a surplus of $690K for the first 9 months of 2010/11.

CHART PLACEHOLDER

Analysis

LeadR. AnsteyQuarterly review by Senior Management Team to ensure a total margin of 0% or better is maintained In progressJul-10

Initiative StatusDate Initiated

-2.00%

-1.50%

-1.00%

-0.50%

0.00%

0.50%

1.00%

2006/07 2007/08 2008/09 2009/10 2010/11 (Apr-Jan)

Total Margin Target



R. Anstey


Indicator Percentage of accountability agreement indicators achieved

Time FrameStrategic Direction

Q3 2010/11

DefinitionOverall percent achievement of 8 accountability agreement indicators: (Total Margin, Current Ratio, % FT Nurses, Weighted Cases, MH Patient Days, Rehab Patient Days, ER Visits, Amb Visits).

Our Performance

FinanceSource

CHART PLACEHOLDER

AnalysisIn Q3 the rehab Patient days target has not been achieved as we are experiencing a decline in this service as patients are being discharged earlier and rehab is taking place on an outpatient basis or at a designated rehab facility. There are possible financial penalties associated with not meeting accountability agreement commitments.

Investigate Rehab patient day volumes R. Anstey, E. Lipnicki Aug-10 In progress

Risk Ratingn/a

SignificanceTrack volumes for the indicators in the Hospital's Accountability Agreement to ensure that we are meeting our MOHLTC commitments.

TargetTSH Target - 80%, higher value is desired.

In progressJul-10Continue to monitor financial results

75%

, n=6

100%

, n=8

88%

, n=7

75%

, n=6 88

%, n

=7

88%

, n=7

0%

20%

40%

60%

80%

100%

120%

2007/08 2008/09 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11

% accountability agreement indicators achieved Target

tsh corporate scorecard - 2010 11 q3 c

Health & Medicine