tsh scorecard corporate - 2010 11 q3 b

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 Q4

Staff 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 Q4

HIT indicator #17, Percentage of equipment cost to total expense 5.2% 5.4% 5.9% R M 13

Number of standardized order sets usedQ1

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 Intranet75% 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 period

Yellow = Performance is below the target, however it has improved over the previous reporting period

Green = Performance indicator has met or exceeded or is not statistically different than the performance target for the current reporting period

Our People: Be the first choice for motivated, talented

people who are inspired to deliver and

support excellent care in a diverse

environment.

Strategic Direction

Our Patients: Create an environment of patient safety that

exceeds our patients' highest expectations

and delivers care that is patient and family

driven.

Service

Excellence: To

provide respectful

and responsive

service to our

patients and each

other.

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.

M = Medium reputational, financial or operational risk

H = High reputational, financial or operational risk

Risk Rating Legend

L = Low reputational, financial or operational risk

The Scarborough Hospital

Corporate Balanced Scorecard

Q3 2010/11

Indicator

Current

Value

Previous

Value Target

Current

Status Risk Rating* Page

Our Patients: Create an environment of

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 period

Status Legend: Risk Rating Legend

Red = 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 risk

Yellow = Performance is below the target, however it has improved over the previous reporting period M = Medium reputational, financial or operational risk

Green = 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

Strategic Direction



Publicly Reported Patient Safety Indicators

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.

Page Addendum

Performance Measurement Summary

Action Plan

Initiative Lead Date Initiated Status

Strategic Direction Our Patients




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

Definition

This indicator reports the 90th Percentile Wait time for all ED Admits with CTAS 1-5

and NonAdmits with CTAS 1-3.

CHART PLACEHOLDER

Significance

This indicator is associated with efficiency within the ED and within the hospital, as

well as with ED patient satisfaction.

Target

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

Risk Rating

High - There will be reputational impact of dissatisfied patients waiting in Emergency

Department and potential financial risk of losing Pay-for-Results funding.

Analysis

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 Ongoing

ED PIP initiated J. Phan Sep-09 Ongoing

Virtual CDU implemented Dr T. Chan Apr-10 Ongoing

Charge Nurse and Triage RN Education T. Reardon Mar-10 Ongoing

Rounding for Outcomes D. Edman Jun-10 Ongoing

Schedule to Demand D. Edman Jun-10 Completed

NP LTC B. Bickle Jun-10 Ongoing

Performance Huddles Leadership Team Jun-10 Ongoing

Schedule to Demand M. Tang Jan-11 Pending

ED PIP Kaizen Events S. Gilbert Aug-10 In progress

15

:54

, n=8

05

1

15

:31

, n=7

93

8

15

:32

, n=8

51

2

16

:47

, n=8

51

7

15

:48

, n=8

88

3

13

:12

, n=9

74

7

15

:12

, n=1

07

27

19

:35

, n=3

51

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 A1


Action Plan





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

Definition

This indicator reports the 90th Percentile Wait time for all ED Admits with CTAS 1-5

and NonAdmits with CTAS 1-3.

CHART PLACEHOLDER

Significance



Target


Risk Rating



Analysis


Status

There are challenges related to specialty consultations and Diagnostic Imaging

procedures.

Initiative Lead Date Initiated

GEM E. Laine Jun-09 Ongoing

Laboratory Technologists G. Bajwa Sep-09 Ongoing

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

NP LTC

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

Virtual CDU implemented Dr T. Chan Apr-10

M. Tang Jun-10 Ongoing

S. Vellani Jun-09 Ongoing

Schedule to Demand M. Tang Jan-11 Pending

Ongoing


Rounding for Outcomes

17

:02

, n=6

38

7

15

:30

, n=6

32

5

16

:45

, n=6

56

1

16

:31

, n=6

67

3

14

:06

, n=6

66

8

13

:36

, n=6

81

2

12

:12

, n=7

16

6

22

:51

, n=2

51

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 A2


Action Plan





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

Definition

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

visits.

CHART PLACEHOLDER

Significance



Target


Risk Rating



Analysis


Status

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

cases.

See and Treat Model of Care


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

Jun-10

Ongoing

RPN Role D. Edman Jun-09 Ongoing

Rounding for Outcomes D. Edman Jun-10 OngoingOngoing

ED Staff Mar-10 In progress

Kaizen Events S. Gilbert Aug-10 In progress

Performance Huddles Leadership Team

06

:37

, n=5

22

0

05

:37

, n=5

47

7

06

:07

, n=5

32

5

05

:54

, n=4

48

7

05

:42

, n=4

77

9

05

:12

, n=4

48

1

04

:48

, n=3

71

3

05

:31

, n=1

24

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 A3


Action Plan





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

Definition

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

visits.

CHART PLACEHOLDER

Significance



Target


Risk Rating



Analysis


Status


cases.


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




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

06

:37

, n=3

90

5

05

:37

, n=3

89

4

06

:07

, n=3

81

1

05

:54

, n=3

27

1

05

:18

, n=3

98

0

05

:00

, n=3

95

0

04

:30

, n=3

97

3

04

:57

, n=1

18

8

0:00

1:00

2:00

3:00

4:00

5:00

6:00

7:00

8:00

9:00

Birchmount Target

Page A4


Action Plan



Jun-10 OngoingNP LTC B. Bickle








Source MOHLTC Wait Times Website / NACRS

Definition

This 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

Significance

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

Target

MOHLTC Target - 90%, higher value is desired.

Risk Rating



Analysis


procedures. A Diagnostic Imaging Kaizen event is taking place to improve

Diagnostic Imaging callbacks wait times.


Time Frame Q4 2010/11 (Jan)




Indicator Percent of CTAS 1&2 meeting 8 hour target

67

%, n

=19

12

68

%, n

=18

54

66

%, n

=17

73

64

%, n

=17

95

69

%, n

=20

45

70

%, n

=23

32

71

%, n

=27

87

67

%, n

=85

5

65

%, n

=12

16

68

%, n

=12

03

69

%, n

=12

28

66

%, n

=11

81

69

%, n

=12

03

73

%, n

=14

01

73

%, n

=14

13

65

%, n

=46

3

66

%, n

=31

28

68

%, n

=30

57

67

%, n

=30

01

65

%, n

=29

76

69

%, n

=32

48

71

%, n

=37

33

71

%, n

=42

00

66

%, n

=13

18

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

General Birchmount TSH Target

Page A5


Action Plan



Jun-10 OngoingNP LTC B. Bickle









Definition

This indicator reports the percentage of ED patients with CTAS 3 who completed

their visit (Registration to Leaving ED) within 6 hours.

CHART PLACEHOLDER

Significance


Target


Risk Rating



Analysis


procedures. A Diagnostic Imaging Kaizen event is taking place to improve

Diagnostic Imaging callbacks wait times.






Indicator Percent of CTAS 3 meeting 6 hour target

51

%, n

=26

04

60

%, n

=30

50

60

%, n

=33

99

60

%, n

=33

81

65

%, n

=37

84

72

%, n

=45

53

73

%, n

=48

77

67

%, n

=14

86

58

%, n

=25

63

63

%, n

=27

71

58

%, n

=27

21

61

%, n

=28

37

65

%, n

=31

30

67

%, n

=32

03

72

%, n

=36

98

66

%, n

=11

67

55

%, n

=51

67

61

%, n

=58

21

59

%, n

=61

20

60

%, n

=62

18

65

%, n

=69

14

70

%, n

=77

56

73

%, n

=85

75

66

%, n

=26

53

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Page A6


Action Plan

Kaizen Events S. Gilbert Aug-10 In progress



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

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




Definition

This 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

Significance


Target


Risk Rating



Analysis


cases.






Indicator Percent of CTAS 4&5 meeting 4 hour target

72

%, n

=38

64

76

%, n

=42

80

73

%, n

=39

74

75

%, n

=34

57

73

%, n

=35

34

79

%, n

=36

00

82

%, n

=31

01

78

%, n

=98

8

66

%, n

=26

44

74

%, n

=29

78

68

%, n

=26

34

71

%, n

=24

06

76

%, n

=30

93

81

%, n

=32

53

85

%, n

=34

38

80

%, n

=97

7

69

%, n

=65

08

75

%, n

=72

58

71

%, n

=66

08

73

%, n

=58

63

74

%, n

=66

27

80

%, n

=68

53

84

%, n

=65

39

79

%, n

=19

65

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 A7


Action Plan





Indicator Rate of Hospital Acquired C. difficile Associated Diarrhea

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

Significance

To 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.

Target

Ontario Average - 0.28, lower value is desired.

Risk Rating

Medium- 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

Feb-11

Time Frame March 2011Source Surveillance and Case Finding

Status

Increased vigilance to IPAC guidelines around C. difficile management for both campuses and enviromental

audits of units E. Lipnicki Jan-11 Ongoing

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. difficileIPAC/Pharmacy

0.1

1, n

=1

0.3

5, n

=3

0.1

2, n

=1

0.0

0, n

=0

0.3

6, n

=3

0.2

3, n

=2

0.2

4, n

=2

0.4

6, n

=4

0.3

7, n

=3

0.1

3, n

=1

0.1

3, n

=1

0.2

6, n

=2

0.5

8, n

=5

0.5

8, n

=5

0.4

5, n

=4 0.4

5, n

=4

0.2

5

0.4

5

0.4

6, n

=3

0.4

8, n

=3

0.0

0, n

=0

0.0

0, n

=0

0.5

1, n

=3

0.4

9, n

=3

0.1

6, n

=1

0.4

9, n

=3

0.0

0, n

=0

0.3

4, n

=2

0.0

0, n

=0

0.0

0, n

=0

0.3

3, n

=2

0.0

0, n

=0

0.0

0, n

=0

0.1

5, n

=1

0.1

7

0.1

5

0.2

6, n

=4

0.4

0, n

=6

0.0

7, n

=1

0.0

0, n

=0

0.4

3, n

=6

0.3

4, n

=5

0.2

0, n

=3

0.4

7, n

=7

0.2

2, n

=3

0.2

2, n

=3

0.0

7, n

=1 0.1

5, n

=2

0.4

7, n

=7

0.3

5, n

=5

0.2

6, n

=4

0.3

2, n

=5

0.2

2

0.3

2

-

0.10

0.20

0.30

0.40

0.50

0.60

0.70

Oct

09

No

v 0

9

Dec

09

Jan

10

Feb

10

Mar

10

Ap

r 1

0

May

10

Jun

10

Jul 1

0

Au

g 1

0

Sep

10

Oct

10

No

v 1

0

Dec

10

Jan

11

Feb

11

Mar

11

General Campus Birchmount Campus

TSH Ontario Average per 1,000 patient-days

TSH Rolling 12-month Average

Page A8


Action Plan

Significance

Higher 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

Target






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

Continue 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 PLACEHOLDERRisk Rating

n/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.


0.1

1, n

=1

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

6, n

=1

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.00

0.01

0.02

0.03

0.04

0.05

0.06




Page A9


Action Plan





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

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

Significance

To track hospital acquired VRE bacteraemia rates in order to identify and implement

necessary prevention plans to reduce the risk of infection from spreading.

Target


Risk Rating

n/a

Analysis

Dec-10

Time Frame Q4 2010/11 Source Surveillance and Case Finding

Status

VRE 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

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

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.000

0.002

0.004

0.006

0.008

0.010

0.012




Page A10


Action Plan





Indicator Rate of Central Line Infection (CLI)

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

Significance

To track hospital acquired CLI rates in order to identify and implement necessary

prevention plans to reduce the risk of infection from spreading.

Target


Risk Rating

n/a

Analysis

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

Ongoing

Chlohexidine dressings to help prevent CLIs


R. Lovinsky

Apr-10 Completed


Ongoing monitoring of insertion and maintenance Bundle


R. Lovinsky

1.1

4, n

=1

0.0

0, n

=0

4.9

8, n

=5

6.3

2, n

=6

0.0

0, n

=0

2.2

1, n

=2

0.0

0, n

=0

2.0

6, n

=3

0.0

0, n

=0

0.0

0, n

=0

1.8

7, n

=1

0.0

0, n

=0

2.3

6, n

=1

2.5

4, n

=1

1.8

8, n

=1

0.0

0, n

=00.7

5, n

=1

0.0

0, n

=0

3.9

0, n

=6 4.5

8, n

=6

0.6

9, n

=1

2.3

1, n

=3

0.6

1, n

=1 1.4

8, 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 A11


Action Plan





Indicator Rate of Ventilator Associated Pneumonia (VAP)

Definition

Overall Rate of hospital acquired Ventilator Associated Pneumonia. Rate is based

on total number of VAP incidents diagnosed after two days of Critical Care

admission per 1000 patient days.

CHART PLACEHOLDER

Significance

To 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


Risk Rating

n/a

Analysis

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.Dr. Clasky, C. Shelton, S.

Cesta, R. Lovinsky

Jan-11 In progress

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


1.7

6, n

=1

0.0

0, n

=0

1.3

1, n

=1

2.4

7, n

=2

0.0

0, n

=0

1.4

0, n

=1

1.1

4, n

=1

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

4.5

6, n

=2

0.0

0, n

=0

0.0

0, n

=0

0.0

0, n

=0

0.9

7, n

=1

0.0

0, n

=0

0.7

8, n

=1

1.5

8, n

=2

1.6

3, n

=2

0.9

0, n

=1

0.7

6, n

=1

0.0

0, 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




Page A12


Action Plan

Status

Ensure 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.


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

PCMs Apr-09 In progress

Source Medical Systems Management (OR System)

Definition

Surgical 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 Rating

n/a

Analysis

Indicator Rate of Timely Administration of Prophylactic Antibiotics - Primary Hip & Knee


Target

Ontario Average - 96.1%, higher value is desired.




Time Frame Q3 2010/11

95

.7%

, n=1

78

99

.2%

, n=2

43

98

.7%

, n=2

31

99

.1%

, n=2

16

99

.4%

, n=1

55

97

.3%

, n=2

15

97

.2%

, n=2

05

95

.9%

, n=7

1

98

.7%

, n=7

4

10

0.0

%, n

=60

95

.9%

, n=7

0

98

.2%

, n=5

6

98

.5%

, n=6

4

10

0.0

%, n

=85

95

.8%

, n=2

49

99

.1%

, n=3

17

99

.0%

, n=2

91

98

.3%

, n=2

86

99

.1%

, n=2

11

97

.6%

, n=2

79

98

.0%

, n=2

90

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 A13


Action Plan





Indicator Wait Time - General Surgery

Definition

Wait 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

Significance

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

Target

MOHLTC Target - 182, lower value is desired.

Risk Rating

n/a

Analysis

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.


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

Hire 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

68

, n=2

79

84

, n=2

79

61

, n=3

87

67

, n=3

14

68

, n=4

75

75

, n=3

97

75

, n=4

15

87

, n=4

99

88

, n=5

24

83

, n=4

19

67

, n=4

57

82

, n=3

56

-

20

40

60

80

100

120

140

160

180

200

TSH Ontario Target

Page A14


Action Plan





Indicator Wait Time - Cancer Surgery

Cancer Surgery is performing well against Ontario average and provincial target.

Patients are seen in a timely manner.

Definition



CHART PLACEHOLDER

Significance


Target


Risk Rating

n/a

Analysis

Dec-10


Status

Ongoing

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


Allocate OR time to services with wait time cases N. Rahim

43

, n=1

00

46

, n=1

59 6

0, n

=21

7

53

, n=2

34

50

, n=1

69

59

, n=1

92 7

4, n

=22

3

49

, n=2

21

57

, n=1

91

54

, n=1

73

65

, n=2

67

-

10

20

30

40

50

60

70

80

90

TSH Ontario Target

Page A15


Action Plan

Significance





Indicator Wait Time - Cataract Surgery


Target



Definition



CHART PLACEHOLDERRisk Rating

n/a

Analysis

Status

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.


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

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

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 progress

Allocate OR time to the Ophthalmology surgeons with wait times exceeding the WTIS target of 182 days N. Rahim Oct-10 In progress

15

7, n

=14

09

13

8, n

=14

23

14

5, n

=14

18

14

5, n

=14

53

15

0, n

=16

13

14

9, n

=13

25

15

5, n

=14

34

16

5, n

=11

34

19

7, n

=14

38

21

2, n

=13

68

22

3, n

=13

31

12

3, n

=12

42

-

50

100

150

200

250

TSH Ontario Target

Page A16


Action Plan





Indicator Wait Time - Total Hip Replacement

Total Hip Replacement Surgery is performing well against Ontario average and

provincial target. Patients are seen in a timely manner.

Definition



CHART PLACEHOLDER

Significance


Target


Risk Rating

n/a

Analysis

Dec-10


Status

Ongoing

Continue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Oct-09 Ongoing



17

1, n

=52

11

7, n

=43

14

5, n

=61

13

0, n

=50

14

6, n

=77

13

1, n

=64

10

8, n

=87

11

4, n

=62

11

6, n

=74

12

4, n

=57

15

1, n

=63

12

3, n

=43

-

50

100

150

200

250

TSH Ontario Target

Page A17


Action Plan





Indicator Wait Time - Total Knee Replacement

Total Knee Replacement Surgery is performing well against Ontario average and

provincial target. Patients are seen in a timely manner.

Definition



CHART PLACEHOLDER

Significance


Target


Risk Rating

n/a

Analysis

Dec-10


Status

Ongoing

Continue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Oct-09 Ongoing



19

2, n

=20

2

15

9, n

=18

1

14

5, n

=24

2

12

4, n

=22

1

11

7, n

=22

3

11

3, n

=20

2

11

4, n

=24

1

12

4, n

=23

6

12

4, n

=22

2

13

0, n

=15

9

15

3, n

=22

2

10

6, n

=14

4

-

50

100

150

200

250

TSH Ontario Target

Page A18


Action Plan





Indicator Wait Time - CT

Definition

Wait time is defined as the 90th percentile number of days wait for CT diagnostic

scan.

CHART PLACEHOLDER

Significance

Track the wait time indicators to ensure that we are meeting our MOHLTC

commitments and meeting the needs of our patients.

Target


Risk Rating

n/a

Analysis


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.

Review existing contrast media delivery policy and explore options for extending contrast appointments T. Jackson Sep-10 Pending

Application 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

T. Jackson Sep-10 Pending

In progress

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

Nov-09

34

, n=5

09

1

41

, n=4

75

7

32

, n=5

03

0

38

, n=5

10

5

38

, n=5

07

7

39

, n=5

17

6

36

, n=5

38

7

29

, n=5

16

9

21

, n=5

51

0

23

, n=5

17

7

23

, n=5

60

5

20

, n=3

96

8

-

5

10

15

20

25

30

35

40

45

50

TSH Ontario Target

Page A19


Action Plan





Indicator Wait Time - MRI

Definition

Wait time is defined as the 90th percentile number of days wait for MRI diagnostic

scan.

CHART PLACEHOLDER

Significance

Track the wait time indicators to ensure that we are meeting our MOHLTC

commitments and meeting the needs of our patients.

Target


Risk Rating

Medium - delays can affect patient care. P4 are the lowest priority. Long waits can

negatively impact reputation.

Analysis


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.


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

61

, n=1

84

4

64

, n=1

63

5

79

, n=1

74

4 10

1, n

=17

18

99

, n=1

84

4

10

3, n

=18

95

11

8, n

=22

40

13

3, n

=21

21

10

9, n

=20

28

10

7, n

=20

85

11

6, n

=21

32

99

, n=1

95

4

-

20

40

60

80

100

120

140

TSH Ontario Target

Page A20


Action Plan

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

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

Target

TSH target is 50 for ED and 73 for IP, higher value is desired. The target is based

on GTA average.



Indicator

Sep-10

Significance

This indicator is a measure of patient's overall impression of the quality of care

received.

Time Frame

Analysis

Sep-10 Ongoing

Patient satisfaction - Overall Impression (Emergency Department and In-patients)

Our Patients

Q3 2010/11

NRC Picker

Risk Rating

High- Reputational, financial or operational risk.

Definition

Response 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?

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

36

.4 n

=15

1

41

.5 n

=13

5

46

.8 n

=15

4

48

.3 n

=14

3

44

.3 n

=21

2

49

.7 n

=19

3

49

.1 n

=11

6

60

.4 n

=35

9

62

.6 n

=34

2

59

.3 n

=32

7

60

.9 n

=32

2

59

.4 n

=33

0

61

.9 n

=31

8

67

.2 n

=27

1

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

Page 2

D. Edman and N. Alli

D. Edman and T. ReardonPatient friendly waiting room

General 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 appropriately

Birchmount Campus

• Re-design waiting room, triage and registration in process

• ED activity board in process

Fast track RAZ patients

General Campus:

• Elite RAZ staff

• Number system to ensure patients are aware of who is next in line

• Pull to RAZ waiting room

Birchmount Campus:

• Elite RAZ staff

• Pull to RAZ waiting room

Completed for Birchmount

Campus

Sep-10

Completed for General CampusSep-10

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

Page 3


Action Plan


In progress

Completed

IPAC Sep-09 Ongoing

OngoingDr. 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

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.

Source

Q3 2010/11

Strategic Direction

CHART PLACEHOLDER

Significance

Provides 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.

Target

TSH 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

Time Frame

T. Jackson Sep-09 - Mar-10

Risk Rating

n/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.

Definition

Percentage of 19 publicly reported patient safety indicators that meet the provincial

targets.

Meditech, NACRS, IPAC, MOHLTC Wait Times Public Website

Completed



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

53

%, n

=10

63

%, n

=12

63

%, n

=12

58

%, n

=11

63

%, n

=12

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

Page 4

Ongoing

E. Lipnicki

Feb-10 Completed

T. Jackson

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

Mar-10

In progress

Jul-10

Ongoing

IPAC Feb-10

Feb-10 Ongoing

In progress

In progress

E. Lipnicki

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

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

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

In progress

In progress

Ongoing

Jun-10

Jul-10

Fall 2010

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

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

Ongoing

N. Rahim

N. Rahim

N. Rahim

IPAC

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

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

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 volumes

Continue 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

To be integrated into base – Sep-

10

Apr-10 Completed

Mar-10

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

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

Page 5


Action Plan

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

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

StatusDate InitiatedLeadInitiative

Strategic Direction

Q4 2010/11 (projected based on Jan-Feb 2011)

Risk Rating

n/a

Analysis

Significance

To track trends in adverse events in order to identify and implement necessary

improvement plans.

Target

TSH 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

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)

Definition

Incident 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)

40

3

46

7

57

6

52

1

62

6

70

5 73

0

74

3

0

100

200

300

400

500

600

700

800

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

2009/10 2010/11 Target

Page 6


Action Plan

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

Definition

The 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.

Significance

This is a global indicator for patient safety and the quality of care provided within a

facility.

Target

TSH Target - 100, lower value is desired.

Risk Rating

n/a

2010/11 (Apr-Dec)

Feb-10

Source

Hospital Standardized Mortality Ratio (HSMR)

Our PatientsStrategic Direction



Indicator

The Canadian Institute for Health Information (CIHI)

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. 1

37

12

9

13

1

12

7

11

2

11

2

80

75

12

2

12

0

11

4

11

4

10

5

97

88

73

13

2

12

6

12

4

12

2

10

9

10

6

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)


Page 7


Action Plan

Continue with the development of a unit based hand hygiene program overseen by IPAC N. Vankoosingh Jul-10 In progress


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

Significance

Proper 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 Rating

n/a

Analysis

Due 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.





Indicator Rate of hand hygiene compliance

90

%, n

=82

0

97

%, n

=87

9

94

%, n

=23

34

98

%, n

=24

30

81

%, n

=34

0

90

%, n

=38

4

98

%, n

=64

4

99

%, n

=65

5

90

%, n

=17

15

94

%, n

=18

18

90

%, n

=46

3

96

%, n

=49

1

93

%, n

=14

64

98

%, n

=15

34

92

%, n

=40

49

96

%, n

=42

48

85

%, n

=80

3

89

%, n

=87

5

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

Page 8


Action Plan


Sep-10

Definition

The 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

Completed

Introduce 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

S. Rai-Lewis

Significance

To 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

Target

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

Risk Rating

n/a

2010/11Time 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

Strategic Direction



Indicator Employee Satisfaction survey results (Commitment composite score)

Our People

37

.5%

, n=1

60

6 50

.9%

, n=1

59

0

0%

10%

20%

30%

40%

50%

60%

2008/09 2010/11

Commitment Score Target

Page 9


Action Plan

Time Frame

Our People



Indicator Physician Satisfaction survey results (Commitment composite score)

Source NRC Picker

CHART PLACEHOLDER

Significance

To track trends in physician satisfaction in order to identify and implement

necessary improvement plans.

Definition

The 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

OngoingDr. S. Jackson

Ongoing

StatusDate InitiatedLead

Apr-10

Initiative

Strategic Direction

Development of robust communication with family physicians Dr. S. Jackson Apr-10

Performance 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

Target

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

Risk Rating

n/a

The development of Physician leadership award Apr-10

Dr. S. Jackson

Ongoing

OngoingThe development of the The Clinical Services Plan

Dr. S. Jackson

Apr-10

28

.8%

, n=1

41

42

.7%

, n=1

51

0%

10%

20%

30%

40%

50%

60%

2008/09 2010/11

Commitment Score Target

Page 10


Action Plan

Transition of clinical resource staff to the new Clinical Resource Leader role R. Seidman-Carlson Apr-10 Completed


Source Internal Tracking

Definition

Percentage 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

Significance

Model of Care positions supports excellent care and full scope of practice and

enhances partnerships between practice and operations.

Target

100%

Risk Rating

n/a

Analysis

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

Strategic Direction Our People

Time Frame 2010/11



Indicator Percentage of defined Model of Care positions transitioned

10

0%

, n=2

1

0%

20%

40%

60%

80%

100%

120%

2010/11

% positions transitioned Target

Page 11


Action Plan


Initialization of Medical Directors performance and evaluations Dr. S. Jackson Apr-10 Ongoing

Source Internal Tracking

Definition

Percentage of Medical Directors with completed annual performance evaluations.

Percentage based on total number of Medical Directors in the hospital.

CHART PLACEHOLDER

Significance

Employee evaluation is important for development of staff and managers to be

aware of employee development needs.

Target

Internal Target - 100%, higher value is desired.

Risk Rating

n/a

Analysis

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

Strategic Direction Our People




Indicator Percentage of Medical Directors with completed performance evaluations

80

%, n

=8

0%

20%

40%

60%

80%

100%

120%

Q3 2010/11

% Medical Directors with completed evaluation Target

Page 12


Action Plan

R. Anstey

LeadInitiative

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

Definition

Total 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

StatusDate Initiated

Significance

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

Target

LHIN Average - 5.9%, target value is desired.

Risk Rating

Medium - Impact would be operational (i.e. quality).

Analysis

In progress

HIT indicator #17, Percentage of equipment cost to total expense

Our Programs, Plans and Partners



Indicator

Strategic 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

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

Page 13


Action Plan

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

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 risks

PMO Advisory Committee Coach assigned to each project to provide advice on Status Report content C. Flemming

Target


Risk Rating

Medium- 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

Significance

A measure of department performance, efficiency and planning.

Time FrameSource

Our Programs, Plans, and Partners

Q3 2010/11Eclipse project management application

Definition

A 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.



Indicator Percentage of PMO project milestones met

Strategic Direction

94

%, n

=15

96

%, n

=22

47

%, n

=20

0%

20%

40%

60%

80%

100%

120%

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

% milestones achieved Target

Page 14


Action Plan

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

C. Flemming Aug-10

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

Significance

Routine uploading of scorecards will facilitate regular review of the indicators and

transparency to the staff and other departments.

Status

Completed



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

Definition

A 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 Our Performance

CHART PLACEHOLDER

Lead

Target


Risk Rating

n/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.).

85

%, n

=17

75

%, n

=15

75

%, n

=15

0%

20%

40%

60%

80%

100%

120%

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

% of posted scorecards Target

Page 15


Action Plan

Lead

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

Initiative StatusDate Initiated

Source Finance

Significance

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

Target

TSH Target - 0%, target value is desired.

Risk Rating

n/a

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

2010/11.

CHART PLACEHOLDER

Analysis

2010/11 (Apr-Jan)

Definition

Total 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 margin

Strategic Direction Our Performance

-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

Page 16


Action Plan


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

Risk Rating

n/a

Significance

Track volumes for the indicators in the Hospital's Accountability Agreement to

ensure that we are meeting our MOHLTC commitments.

Target

TSH Target - 80%, higher value is desired.

In progressJul-10Continue to monitor financial results

Our Performance

FinanceSource

CHART PLACEHOLDER

Analysis

In 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.

R. Anstey



Indicator Percentage of accountability agreement indicators achieved

Time Frame

Strategic Direction

Q3 2010/11

Definition

Overall 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).

75

%, n

=6

10

0%

, 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

Page 17

tsh scorecard corporate - 2010 11 q3 b

Health & Medicine