Tsh scorecard corporate - 2010 11 q4[1]

Page 1

Indicator1st Qtr

ReportedCurrent Value

Previous Value Target

Current Status

Risk Rating* Page

Percentage of publicly reported patient safety indicators meeting the provincial target (see addendum) 63% 63% 100% Y n/a 2

Number of incident reports completed (medication and non-medication) 768 730 490 G n/a 4

Percentage of staff and physicians educated in Mission, Vision and Values defined behaviours Q4 79% 75% G n/a 5

Employee Satisfaction survey results (Commitment composite score) 50.9% 37.5% 59% Y n/a 6

Physician Satisfaction survey results (Commitment composite score) 42.7% 28.8% 43% Y n/a 7

Percentage of defined Model of Care positions transitioned 100% 100% 100% G n/a 8

Percentage of leaders with completed performance evaluations Q4 21% 50% Y n/a 9

Percentage of Medical Directors with completed performance evaluations Q3 100% 80% 100% G n/a 10

Percentage of non-union staff with completed performance evaluations Q4 46% 50% Y n/a 11

Percentage of unionized staff with completed performance evaluations Q4 6% 30% Y n/a 12

Percentage of leaders educated in LEAN methodology Q4 17% 100% Y n/a 13

HIT indicator #17, Percentage of equipment cost to total expense 5.2% 5.4% 5.9% R M 14

Number of standardized order sets used Q1 2011/12

Percentage of Clinical Service Plan (CSP) recommendations implemented Q4 2011/12

100%

Percentage of PMO project milestones met 40% 47% 80% R L 15

Percentage of Programs and Departments with performance indicator scorecards and action plans that are posted and updated quarterly on the Intranet 65% 75% 100% R L 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 H = High reputational, financial or operational risk

Risk Rating LegendL = Low reputational, financial or operational risk

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

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

The Scarborough HospitalCorporate Balanced Scorecard

Q4 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.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.

M = Medium reputational, financial or operational risk

Addendum 1

TSH Strategic Direction Indicator Origin QIP DimensionQIP Priority

Rating1st Qtr

Reported Current Value Previous Value 2010/11 Target Current Status Risk Rating*2011/12 QIP

Target Page

1. Rate of Hospital Acquired C. difficile Associated Diarrhea (CDI) QIP / PRPSI Safety 2 0.32 0.26 0.33 G n/a 0.28 A12. Rate of Central Line Infection (CLI) QIP / PRPSI Safety 1 1.48 0.00 0.79 R L 1.93 A23. Rate of Ventilator Associated Pneumonia (VAP) QIP / PRPSI Safety 2 0.00 0.61 1.33 G n/a 1.46 A34. Rate of hand hygiene compliance before initial patient/patient environment contact QIP Safety 2 83% 93% 90% R L 90% A45. Rate of hand hygiene compliance after patient/patient environment contact 90% 100% 90% G n/a A46. Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia PRPSI 0.00 0.00 0.02 G n/a A57. Rate of Hospital Acquired Vancomycin Resistant Enterococcus (VRE) Bacteraemia PRPSI 0.00 0.00 0.00 G n/a A68. Rate of Timely Administration of Prophylactic Antibiotics - Primary Hip PRPSI 100.0% 97.1% 96.1% G n/a A79. Rate of Timely Administration of Prophylactic Antibiotics - Primary Knee PRPSI 96.6% 97.7% 96.1% G n/a A8

10. WHO surgical checklist compliance 100% 100% 98% G n/a A911. Hospital Standardized Mortality Ratio (HSMR) QIP Effectiveness 2 74 84 100 G n/a 100 A1012. 30 day readmission rate to any facility - All tracked CMGs QIP Effectiveness 2 14.5% 14.5% 14.5% G n/a 14.5% A1113. Percentage of ALC days QIP / HSAA Effectiveness 1 15.9% 12.2% 12.2% R H 12.2% A1214. Emergency Department Wait Time for High Acuity Visits - General Campus PRPSI 13:49 14:33 8:00 Y n/a A1415. Emergency Department Wait Time for High Acuity Visits - Birchmount Campus PRPSI 19:07 12:07 8:00 R H A1516. Emergency Department Wait Time for Low Acuity Visits - General Campus PRPSI 5:02 4:47 4:00 R H A1617. Emergency Department Wait Time for Low Acuity Visits - Birchmount Campus PRPSI 4:50 4:20 4:00 R H A1718. Admitted patient treated within the LOS target of less than 8 hours - General Campus P4R 30% 32% 31% R H A1819. Admitted patient treated within the LOS target of less than 8 hours - Birchmount Campus P4R 27% 34% 36% R H A1920. Non-admitted high acuity patients treated within their respective targets of <=8 hours - General Campus P4R 91% 90% 87% G n/a A2021. Non-admitted high acuity patients treated within their respective targets of <=8 hours - Birchmount Campus P4R 89% 91% 90% R H A2122. Non-admitted low acuity patients treated within their respective targets of <=4 hours - General Campus P4R 85% 81% 81% G n/a A2223. Non-admitted low acuity patients treated within their respective targets of <=4 hours - Birchmount Campus P4R 81% 83% 77% G n/a A2324. 90th percentile physician initial assessment time - General Campus PRPSI 4:21 4:35 4:06 Y n/a A2425. 90th percentile physician initial assessment time - Birchmount Campus PRPSI 3:40 3:06 3:48 G n/a A2526. 90th Percentile ER Lengh of Stay for Admitted Patients QIP / HSAA Access 1 44:14 36:43 25:00 R H 25:00 A2627. 90th Percentile ER Length of Stay for Complex Condition Patients QIP / HSAA Access 1 8:01 8:19 8:00 Y n/a 8:00 A2728. Wait Time - General Surgery HSAA / PRPSI 76 67 182 G n/a A2829. Wait Time - Cancer Surgery HSAA / PRPSI 53 54 84 G n/a A2930. Wait Time - Cataract Surgery HSAA / PRPSI 120 225 182 G n/a A3031. Wait Time - Total Hip Replacement HSAA / PRPSI 131 151 182 G n/a A3132. Wait time - Total Knee Replacement HSAA / PRPSI 108 153 182 G n/a A3233. Wait Time - CT HSAA / PRPSI 19 23 28 G n/a A3334. Wait Time - MRI HSAA / PRPSI 97 116 28 Y n/a A3435. Patient satisfaction - Overall Impression: Emergency Department QIP Patient-Centred 1 54.5 46.7 50 G n/a 50 A3536. Patient satisfaction - Overall Impression: In-patients QIP Patient-Centred 1 59.2 66.3 70 R H 70 A3637. Repeat Unplanned Emergency Visited within 30 Days for Mental Health Conditions HSAA Q1 2011/1238. Repeat Unplanned Emergency Visited within 30 Days for Substance Abuse Conditions HSAA Q1 2011/12


Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA) and Publicly Reported Patient Safety Indicators (PRPSI)

Our Patients

Indicator

Addendum 2

TSH Strategic Direction Indicator Origin QIP DimensionQIP Priority

Rating1st Qtr

Reported Current Value Previous Value 2010/11 Target Current Status Risk Rating*2011/12 QIP

Target Page



Indicator

39. Total margin QIP / HSAA Effectiveness 1 0.04% -0.31% 0% G n/a 0% A3840. Current Ratio HSAA 0.38 0.39 0.39 R M A3941. Total weighted cases (Inpatient and Day Surgery) HSAA 43,171 43,027 40,712 G n/a A4042. Mental Health Patient Days HSAA 16,027 15,425 15,000 G n/a A4143. Rehab Patient Days HSAA 2,740 3,221 3,530 R M A4244. Emergency Visits HSAA 103,683 99,915 98,000 G n/a A4345. Ambulatory Visits (excluding ER) HSAA 307,556 303,662 294,773 G n/a A4446. Total Hip and Knee Replacement HSAA 1,296 1,275 1,225 G n/a A4547. Cataract Surgeries HSAA 6,414 5,894 5,815 G M A4648. Computed Tomography (CT) HSAA 8,072 8,352 7,245 G n/a A4749. Magnetic Resonance Imaging (MRI) HSAA 6,701 6,123 5,657 G n/a A48

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

Current Status Legend: Priority Legend

Risk Rating Legend Priority 2 - Moderate priority: • Current performance just below “benchmark” (if one exists) or below long term goal; room for improvement

Priority 3 - Lower priority: • Current performance at/above” benchmark”, provincial rate or long term goal • Organizational priority

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.

L = Low reputational, financial or operational risk

M = Medium reputational, financial or operational risk

H = High reputational, financial or operational risk

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

• Aligned with organizational priorities/strategic plan, defined accreditation priority or recommendation, funding tied to initiative, aligned with government agenda

• Aligned with organizational priorities/strategic plan, defined accreditation priority or recommendation, funding tied to initiative, aligned with government agenda

Our Performance

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

• Current performance below “benchmark” (if one exists) or below long term goal; significant improvements required or improvement initiatives underway.

Priority 1 - Highest priority

Page A1

Performance Measurement Summary

Action Plan

March 2011Surveillance and Case Finding

Strategic Direction Our Patients

CHART PLACEHOLDER

n/a n/a

Source

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.

Analysis



Indicator QIP - Rate of Hospital Acquired C. difficile Associated Diarrhea

Time Frame

Current StatusIndicator meeting or exceeding target, no action plan required n/a

Risk Ratingn/a

TargetOntario Average - 0.33, lower value is desired.

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.C. difficile is communicable. It can live in the environment and on other surfaces. Rigorous cleaning regimes, patient isolation and hand washing are some of the strategies used to combat C. difficile.

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated

QIP use rate for January to December 2010. 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.

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

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

0.00

, 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

-

0.10

0.20

0.30

0.40

0.50

0.60

0.70

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

General Campus Birchmount Campus

TSH Ontario Average per 1,000 patient-days

TSH Rolling 12-month Average QIP Reported Value=0.26

Page A2


Action Plan

Data collection in progress

Source

Date Initiated

Mar-11

Apr-10

Expanded data collection to include the program that the hemodialysis patients are coming from, type of line being used, and CLI reduction interventions such as the use of chlorhexidine dressing and bath to investigate higher rate of CLI in the hemodialysis population by Q2 of 2011/12

H. Clasky, R. Lovinsky, IPAC

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 - 0.79, lower value is desired.

Risk RatingLow - 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.

AnalysisQIP use rate for January to December 2010. There has been a marked improvement to the number of CLI cases in 2010/11 at the General Campus. CLI strategies to standardize processes across the campuses is showing improvements in the rates. There is lower rate of infection associated with PICC, therefore the use of PICC has been increased.

Surveillance and Case Finding



Indicator QIP - Rate of Central Line Infection (CLI)

Monthly monitoring of insertions and maintenance Bundle which includes hand hygiene, maximal barrier precautions, and chlorhexidine skin antisepsis and optimal catheter side selection to adhere the compliance of 90% to decrease rate of CLI for the next quarter

H. Clasky, D. Rose, P. Tamlin, R. Lovinsky, C. Shelton

Monthly audits

Strategic Direction Our PatientsTime Frame Q4 2010/11

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current Status

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

0.00

, n=0

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

0.00

, n=0

1.48

, n=3

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

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 A3


Action Plan


Date Initiatedn/a

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead

Source Surveillance and Case Finding

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 - 1.33, lower value is desired.

Risk Ratingn/a

AnalysisQIP use rate for January to December 2010. There were zero VAP case identified in the Q4. Currently meeting target.

Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a



Indicator QIP - 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.

0.00

, n=0

0.00

, n=0

0.00

, n=0

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

0.00

, n=0

0.00

, n=0

0.00

, n=0

1.58

, n=2

1.63

, n=2

0.90

, n=1

0.76

, n=1

0.00

, n=0

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

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 A4


Action Plan

Source

Date InitiatedMar-11

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 RatingLow- Reputational, financial or operational risk.

AnalysisQIP use rate for 2009/10, only for before patient contact. Due to the lack of hand hygiene auditors and the VRE issue, there were not enough audits done to report for Q3 at the General Campus. In Q4 IPAC trained unit based auditors to carryout the audits to meet mandatory reporting requirements. The results of the before compliance are below TSH target; however, well above the Ontario average of 72.17%.




Indicator QIP - Rate of hand hygiene complianceStrategic Direction Our PatientsTime Frame Q4 2010/11

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusDevelopment of a audit process to monitor unit based hand hygiene audits and program overseen by IPAC and Decision Support. Monthly audit to observe number of times hand hygiene performed before patient contact.

IPAC In progress, on a monthly basis

95%

, n=5

7

97%

, n=5

8

100%

, n=7

88%

, n=7

0%, n

=0

0%, n

=0

0%, n

=0

0%, n

=0

0%, n

=0

0%, n

=0

81%

, n=2

68

90%

, n=3

01

84%

, n=3

34

88%

, n=3

54

85%

, n=1

063

92%

, n=1

180

87%

, n=3

60

96%

, n=3

92

96%

, n=2

5

96%

, n=2

5

93%

, n=5

2

100%

, n=5

6

93%

, n=6

2

90%

, n=6

0

85%

, n=3

91

89%

, n=4

12

85%

, n=1

070

92%

, n=1

187

87%

, n=3

60

96%

, n=3

92

96%

, n=2

5

96%

, n=2

5

93%

, n=5

2

100%

, n=5

6

83%

, n=3

30

90%

, n=3

61

0%

20%

40%

60%

80%

100%

120%

140%

Before After Before After Before After Before After Before After Before After

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

General Campus Birchmount Campus TSH Target QIP Reported Value=92.3%

Page A5


Action Plan


Date Initiatedn/a

Current StatusIndicator meeting or exceeding target, no action plan required n/a

Source Surveillance and Case Finding

TargetOntario Average - 0.02, lower value is desired.Risk Ratingn/a

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

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Leadn/a



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

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.

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.04

, n=1

0.04

, n=1

0.00

, n=0

0.00

, n=0

0.04

, n=1

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.

02, n

=1

0.02

, n=1

0.02

, n=1

0.00

, n=0

0.00

, n=0 0.

02, n

=1

0.00

, n=0

0.00

, n=0

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

0.16



TSH Rolling 12-month Average

Page A6


Action Plan

Time Frame Q4 2010/11

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.

TargetOntario Average - 0.00, lower value is desired.

Risk Ratingn/a

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

Source

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.




Indicator Rate of Hospital Acquired Vancomycin Resistant Enterococcus (VRE) BacteraemiaStrategic Direction Our Patients

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a

Date Initiatedn/a

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

0.00

, n=0

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



TSH Rolling 12-month Average

Page A7


Action Plan


Date Initiatedn/a


Source Medical Systems Management (OR System)

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.

TargetOntario Average - 96.1%, higher value is desired.

Risk Ratingn/a

AnalysisAll surgeons’ offices now have pre-printed orders. Work continues on ensuring a good process for improvement on this indicator. The drop at General was due to two cases where the patient did not receive a prophylactic antibiotic within the appropriate recommended time. One case was delayed because of an earlier case running late and the second was delayed because there was a delay in the turnover of the operating room. TSH continues to exceed GTA average.




Indicator Rate of Timely Administration of Prophylactic Antibiotics - Primary Hip

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.

92.9

%, n

=39

98.5

%, n

=66

98.0

%, n

=49

98.4

%, n

=62

100.

0%, n

=42

96.2

%, n

=50

100%

, n=3

2

95.0

%, n

=19

100.

0%, n

=16

100.

0%, n

=14

92.9

%, n

=13

91.7

%, n

=11

100.

0%, n

=18

100%

, n=1

0

93.5

%, n

=58

98.8

%, n

=82

98.4

%, n

=63

97.4

%, n

=75

98.1

%, n

=53

97.1

%, n

=68

100%

, n=4

2

0%

20%

40%

60%

80%

100%

120%

140%

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 Target

Page A8


Action Plan


Date Initiatedn/a


Source Medical Systems Management (OR System)

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.

TargetOntario Average - 96.1%, higher value is desired.

Risk Ratingn/a

AnalysisAll 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.




Indicator Rate of Timely Administration of Prophylactic Antibiotics - Primary Knee

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.

96.5

%, n

=139

99.4

%, n

=177

98.9

%, n

=182

99.4

%, n

=154

99.1

%, n

=113

97.6

%, n

=165

96.6

%, n

=140

96.3

%, n

=52

98.3

%, n

=58

100.

0%, n

=45

96.6

%, n

=57

100.

0%, n

=45

97.9

%, n

=46

100.

0%, n

=43

96.5

%, n

=191

99.2

%, n

=235

99.1

%, n

=227

98.6

%, n

=211

99.4

%, n

=158

97.7

%, n

=211

96.6

%, n

=183

0%

20%

40%

60%

80%

100%

120%

140%

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


Page A9


Action Plan

Source Surgical Efficiency Target Program

DefinitionPercentage of cases carried out with checklist. Based on total number of surgical cases performed. The Surgical Safety Checklist is a one-page list of 26 of the most common tasks and items that operating room teams carry out to ensure patient safety.

CHART PLACEHOLDER

SignificanceOriginally developed as a tool to support patient care though professional preparation and teamwork, the consistent use of this checklist has been shown to reduce the rates of death and complications associated with surgical care.

Surgery implemented surgical check list in February 2010 at the General Campus and in March 2010 at the Birchmount Campus. Internal reporting of this indicator took place in April 2010. Public reporting of this indicator started in June 2010.

Target Ontario SETP Average - 98%, higher value is desired.

Risk Ratingn/a

Analysis



Indicator WHO surgical checklist complianceStrategic Direction Our PatientsTime Frame February 2011

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/an/a

Date Initiated

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

0%

20%

40%

60%

80%

100%

120%

Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11


Page A10


Action Plan

Strategic Direction Our Patients2010/11 (Apr-Dec)

QIP use HSMR for 2009/10. 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.

CHART PLACEHOLDER

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

Analysis

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.

TargetTSH Target - 100, lower value is desired.

Risk Ratingn/a

Date Initiatedn/a

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound)



Indicator QIP - Hospital Standardized Mortality Ratio (HSMR)

Lead

Time Frame


Source The Canadian Institute for Health Information (CIHI)

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)

General Birchmount TSH Target QIP Reported Value=84

Page A11


Action Plan



Indicator QIP - 30 day readmission rate to any facility - All tracked CMGs

SignificanceReadmission rates have been used as a measure of the quality of inpatient care and discharge planning; e.g. successful transition to effective community resources.

Our PerformanceStrategic DirectionTime Frame Q1 2010/11

CHART PLACEHOLDER

QIP use percent for Q1 2010/11. We will monitor readmission rate and investigate the factors that resulted in need for readmission.

n/a

MOHLTC Website

Analysis

DefinitionThe number of patients readmitted to any facility for non-elective inpatient care within 30 days of discharge. This is compared to the number of expected non-elective readmissions using data from all Ontario acute hospitals. These are for acute inpatients in the specified CMGs for Stroke, COPD, CHF, Cardiac, pneumonia, diabetes and GI; with age restrictions in some of the CMGs. The data excludes acute transfers and patient sign-out against medical advice.

Date Initiated

Risk Ratingn/a

TargetInternal Target - 14.5%, this is the Expected Readmission rate for TSH average for 2009 calendar year. Expected Readmission is determined by looking at CMG, age, gender, prior hospitalizations, quarterly seasonality and comorbidity. Lower value is desired.

Source

Current StatusIndicator meeting or exceeding target, no action plan required n/a n/aSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead

15.2

%, n

=139

14.8

%, n

=124

16.5

%, n

=149

14.5

%, n

=132

14.5

%, n

=134

0%

5%

10%

15%

20%

25%

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

TSH Target QIP Reported Value=14.5%

Page A12


Action Plan

Risk RatingHigh- Reputational, financial or operational risk.

QIP use percent for Q2 2010/11. ALC patient days in comparison to the acute patient days is above target for Q4 2010/11. Ongoing initiative results will result in better processes to disposition patients to a more appropriate setting.


SignificanceThis indicator identifies barriers to alternative placement and monitor the prevalence of conditions treated with Alternate Level of Care (ALC) status.

TargetCELHIN Target - 12.2%, target value is desired.

Analysis

Strategic Direction Our PerformanceTime Frame Q4 2010/11 Source Health Records - DAD

DefinitionThe percentage of patient days awaiting alternative care in acute bed, excluding newborns.

CHART PLACEHOLDER

Jan-11

Indicator QIP - Percentage of ALC patients days/patient days in Acute beds

Date Initiated



Current StatusThe Home First Initiative with CCAC will reduce the number of ALC-LTC patients by jointly reviewing all patients for potential to return home prior to ALC designation on a daily basis. All ALC-LTC alerts will be reviewed weekly by a joint committee with CCAC/CCS to identify alternate or preventable strategies to becoming ALC. 100% of all ALC-LTC alerts will be reviewed

N. Veloso, S.Greenwood, J. Miller

Ongoing, processes and meetings all in place as completed

12.8

%, n

=503

1

13.5

%, n

=518

0

17.9

%, n

=758

1

13.4

%, n

=513

7

14.4

%, n

=548

8

13.4

%, n

=527

3

12.2

%, n

=451

4

15.9

%, n

=667

9

0%

5%

10%

15%

20%

25%

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

TSH Target QIP Reported Value=13.4%

Page A13

April 2011 (inclusion of weekly performance monitoring)

Interprofessional daily bullet rounds on inpatient units introduced through Patient Flow PIP initiative enables improved discharge coordination to decrease length of stay for patients and avoid ALC. LOS and ALC case metrics on the DART tracker are reviewed during bullet rounds weekly on all medicine units to identify improvement strategies and action plans. 100% of Medicine inpatient units (General and Birchmount) will hold rounds 5/7 days/week

N. Veloso, L. Kane, M. DePaulsen, S. Johnson, T.Early

Ongoing

The GAIN clinic will provide timely geriatric assessments and interventions for frail seniors to facilitate earlier discharge from hospital and optimize patients returninig home upon discharge. The number of post discharge referrals to the GAIN clinic are reviewed weekly. 30% of GAIN referrals will target frail seniors being discharged from hospital in 2011/12

D. Driver, N. Veloso Completed implementation

The Geriatric Activation Program (GAP) provides enhanced therapy and activation for frail seniors upon admission to a hospitalist unit to optimize discharge home again and avoid ALC. The number of GAP referrals are tracked through meditech system for those paitents received enhanced therapy services. The GAP will provide service to 300 patients on the 2 hospitalist units in 2011/12

L. Kane, A. Sideris, N. Veloso

Completed implementationJan-11

Jan-11

Page A14


Action PlanLead

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.

Current StatusMobile Admission Team (MAT) to be implemented June 2011

Date Initiated

Apr-11

Apr-11


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

Risk Ratingn/a

CHART PLACEHOLDER

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

Analysis



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

Source

Strategic Direction Our PatientsTime Frame

Apr-11

MAT ensure available bed ready (ABR) to in-patient unit transfer time of 45 minutes MAT Not meeting target currently, as MAT develops will review processes and targets

Admitted Mental Health patients to in-patient bed within 8 hours by September 2011

Q4 2010/11

S.Engels, A.MacKinnon

Implementing role change for Crisis Team – from consultant to patient flow coordinator

MOHLTC Wait Times Website / NACRS

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

May-11

Developing terms of reference by June 2011; site visit to Sunnybrook May 2011; hire manager of patient flow and access June 2011

Patient Flow and Access Steering Committee implemented by June 30, 2011 A.MacKinnon

Jun-11

Collect and analyze data for specialist consultant time to ED by April 1, 2011 A.MacKinnon, N.Mills Break down consultant time data to request date/time and arrival date/time by May 2011; complete root cause analysis on May data in June 2011

N.Veloso, A.MacKinnon Funding approved by CELHIN April 2011; post position by May 2011 with interview and hire June 2011

15:5

4, n

=805

1

15:3

1, n

=793

8

15:3

2, n

=851

2

16:4

7, n

=851

7

16:0

4, n

=888

3

13:1

8, n

=974

7

14:3

3, n

=107

27

13:4

9, n

=104

94

0:00

2:00

4:00

6:00

8:00

10:00

12:00

14:00

16:00

18:00

20:00

22:00

24:00

26:00

28:00

90th percentile Target TSH Median TSH Average

Page A15


Action Plan

May-11

Apr-11

Apr-11

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

CHART PLACEHOLDER



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


Apr-11

Patient Flow and Access Steering Committee implemented by June 30, 2011

Source

Date Initiated

Jun-11

A.MacKinnon Developing terms of reference by June 2011; site visit to Sunnybrook May 2011; hire manager of patient flow and access June 2011

Collect and analyze data for specialist consultant time to ED by April 1, 2011 A.MacKinnon, N.Mills



Indicator Emergency Department Wait Time for High Acuity Visits - Birchmount CampusStrategic Direction Our PatientsTime Frame Q4 2010/11


SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusMobile Admission Team (MAT) to be implemented June 2011 N.Veloso, A.MacKinnon Funding approved by CELHIN April 2011; post position

by May 2011 with interview and hire June 2011


Break down consultant time data to request date/time and arrival date/time by May 2011; complete root cause analysis on May data in June 2011


Admitted Mental Health patients to in-patient bed within 8 hours by September 2011 S.Engels, A.MacKinnon

17:0

2, n

=638

7

15:3

0, n

=632

5

16:4

5, n

=656

1

16:3

1, n

=667

3

13:5

7, n

=666

8

13:3

5, n

=681

2

12:0

7, n

=716

6 19:0

7, n

=725

7

0:002:004:006:008:00

10:0012:0014:0016:0018:0020:0022:0024:0026:0028:0030:0032:00


Page A16


Action PlanSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusAll Rapid Assessment Zone (RAZ) patients will have an ALOS of 3.5 hours at the Birchmount Campus and 4.0 hours at the General Campus by September 2011

Date Initiated

May-11

Apr-11D.Edman, T.Reardon, N.Alli

1. Implemented an elite RAZ team April 20112. Hours of operation changed from 12 hours to 24 hours May 2011

RAZ dedicated physician shift to be implemented in October 2011



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

Source



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



CHART PLACEHOLDER


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

Dr. T.Chan Currently recruiting, interviewing and preparing for appointment for October 2011

Through the implementation of a Geriatric Mental Health program, the ED LOS of elders with delirium, dementia and depression will be < 8 hours by December 2011

E.Laine, S.Vellani 1. Program approved by CE LHIN April 20112. Implementation team struck May 2011

May-11

6:37

, n=5

220

5:37

, n=5

477

6:07

, n=5

325

5:54

, n=4

487

5:28

, n=4

779

5:05

, n=4

481

4:47

, n=3

713

5:02

, n=3

520

0:00

1:00

2:00

3:00

4:00

5:00

6:00

7:00

8:00

9:00


Page A17


Action Plan

May-11

Date Initiated

May-11


Time Frame

Apr-11

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

CHART PLACEHOLDER




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

Q4 2010/11Source MOHLTC Wait Times Website / NACRS



Indicator Emergency Department Wait Time for Low Acuity Visits - Birchmount CampusStrategic Direction Our Patients


E.Laine, S.Vellani 1. Program approved by CE LHIN April 20112. Implementation team struck May 2011

Current StatusAll Rapid Assessment Zone (RAZ) patients will have an ALOS of 3.5 hours at the Birchmount Campus and 4.0 hours at the General Campus by September 2011

D.Edman, T.Reardon, N.Alli

1. Implemented an elite RAZ team April 20112. Hours of operation changed from 12 hours to 24 hours May 2011

RAZ dedicated physician shift to be implemented in October 2011 Dr. T.Chan Currently recruiting, interviewing and preparing for appointment for October 2011

6:37

, n=3

905

5:37

, n=3

894

6:07

, n=3

811

5:54

, n=3

271

5:12

, n=3

980

4:55

, n=3

950

4:20

, n=3

973

4:50

, n=3

402

0:00

1:00

2:00

3:00

4:00

5:00

6:00

7:00

8:00

9:00


Page A18


Action Plan



Indicator Admitted patient treated within the LOS target of less than 8 hours - General CampusStrategic Direction Our PatientsTime Frame March 2011Source NACRS

DefinitionPercent of admitted patient treated within the LOS target of less than or equal to 8 hours, measured from registration to leaving General Campus Emergency Department.

CHART PLACEHOLDER

SignificanceThis is to meet Pay-for-Results expectations. There could be funding impact if targets are not met.

TargetCELHIN Target - 31%, higher 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


There are challenges related to discharge processes, bed turnover times, and bed availability. As a result of ED PIP, white boards, discharge huddles, and patient education the 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.

Date InitiatedMay-11


by May 2011 with interview and hire June 2011MAT ensure available bed ready (ABR) to in-patient unit transfer time of 45 minutes MAT Not meeting target currently, as MAT develops will

review processes and targetsJun-11


Patient Flow and Access Steering Committee implemented by June 30, 2011 A.MacKinnon Developing terms of reference by June 2011; site visit to Sunnybrook May 2011; hire manager of patient flow and access June 2011


Apr-11

Apr-11

Apr-11

29%

, n=1

54

20%

, n=1

17

28%

, n=1

64

17%

, n=1

04

22%

, n=1

11 28%

, n=1

54

27%

, n=1

49

22%

, n=1

28

24%

, n=1

34

26%

, n=1

41

27%

, n=1

46

25%

, n=1

33

21%

, n=9

8

24%

, n=1

17

20%

, n=1

27

22%

, n=1

30

32%

, n=1

63

30%

, n=1

97

0%

5%

10%

15%

20%

25%

30%

35%

40%

Percent Target

Page A19


Action Plan



Indicator Admitted patient treated within the LOS target of less than 8 hours - Birchmount CampusStrategic Direction Our PatientsTime Frame March 2011Source NACRS

DefinitionPercent of admitted patient treated within the LOS target of less than or equal to 8 hours, measured from registration to leaving Birchmount Campus Emergency Department.

CHART PLACEHOLDER




Analysis


There are challenges related to discharge processes, bed turnover times, and bed availability. As a result of ED PIP, white boards, discharge huddles, and patient education the 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.








Apr-11

Apr-11

Apr-11

30%

, n=1

51

30%

, n=1

50 37%

, n=2

11

30%

, n=1

68

32%

, n=1

63

32%

, n=1

82

27%

, n=1

39

36%

, n=1

84

37%

, n=1

82

38%

, n=2

10

35%

, n=1

81

47%

, n=2

38

40%

, n=1

84

47%

, n=1

93

33%

, n=1

93

28%

, n=1

67

34%

, n=1

40

27%

, n=1

62

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Percent Target

Page A20


Action Plan



Indicator Non-admitted high acuity patients treated within their respective targets of <=8 hours - General CampusStrategic Direction Our PatientsTime Frame March 2011Source NACRS

DefinitionPercent of non-admit CTAS 1, 2 and 3 patients treated within 8 hours, measured from registration to leaving General Campus Emergency Department.

CHART PLACEHOLDER



Risk Ratingn/a

Analysis

Lead Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a

Consistently met the target for last 9 months.

Date Initiatedn/a


83%

, n=1

,901

82%

, n=1

,899

84%

, n=1

,850

80%

, n=1

,799

83%

, n=1

,805

87%

, n=2

,111

87%

, n=1

,979

87%

, n=2

,136

86%

, n=2

,103

89%

, n=2

,335

88%

, n=2

,405

91%

, n=2

,519

90%

, n=2

,618

92%

, n=2

,545

88%

, n=2

,809

89%

, n=2

,604

90%

, n=2

,463

91%

, n=2

,802

0%

20%

40%

60%

80%

100%

Percent Target

Page A21


Action Plan



Indicator Non-admitted high acuity patients treated within their respective targets of <=8 hours - Birchmount CampusStrategic Direction Our PatientsTime Frame March 2011Source NACRS

DefinitionPercent of non-admit CTAS 1, 2 and 3 patients treated within 8 hours, measured from registration to leaving Birchmount Campus Emergency Department.

CHART PLACEHOLDER




Analysis


Consistently moving toward meeting our target. We have been close to target for last 8 months.








Apr-11

Apr-11

Apr-11

83%

, n=1

,400

85%

, n=1

,493

85%

, n=1

,307

84%

, n=1

,348

85%

, n=1

,294

87%

, n=1

,586

88%

, n=1

,407

86%

, n=1

,561

87%

, n=1

,513

86%

, n=1

,439

89%

, n=1

,698

89%

, n=1

,494

89%

, n=1

,435

93%

, n=1

,488

91%

, n=1

,923

89%

, n=1

,710

91%

, n=1

,598

89%

, n=1

,764

0%

20%

40%

60%

80%

100%

Percent Target

Page A22


Action Plan



We are currently meeting target. We have met or been close to target the past 10 months.

Indicator Non-admitted low acuity patients treated within their respective targets of <=4 hours - General CampusStrategic Direction Our Patients


Time Frame March 2011Source NACRS

DefinitionPercent of non-admit CTAS 4 and 5 patients treated within 4 hours, measured from registration to leaving General Campus Emergency Department.

CHART PLACEHOLDER


Risk Ratingn/a

Analysis


Date Initiatedn/a


76%

, n=1

,383

74%

, n=1

,376

74%

, n=1

,203

74%

, n=1

,079

77%

, n=1

,068

79%

, n=1

,301

74%

, n=1

,151

74%

, n=1

,214

80%

, n=1

,242

81%

, n=1

,349

78%

, n=1

,174

84%

, n=1

,104

86%

, n=1

,079

84%

, n=9

86

79%

, n=9

88

80%

, n=9

95

81%

, n=8

90

85%

, n=9

97

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percent Target

Page A23


Action Plan



Indicator Non-admitted low acuity patients treated within their respective targets of <=4 hours - Birchmount CampusStrategic Direction Our PatientsTime Frame March 2011Source NACRS

DefinitionPercent of non-admit CTAS 4 and 5 patients treated within 4 hours, measured from registration to leaving Birchmount Campus Emergency Department.

CHART PLACEHOLDER



Risk Ratingn/a

Analysis


Significant progress has been made through ED PIP and the re-design of the Rapid Assessment Zone (RAZ) leading to consistently meeting or exceeding target.

Date Initiatedn/a


68%

, n=8

45

65%

, n=8

91

74%

, n=8

89

73%

, n=8

35

76%

, n=7

49

73%

, n=8

29

80%

, n=9

89

75%

, n=1

,084

79%

, n=1

,013

80%

, n=1

,168

82%

, n=1

,073

84%

, n=1

,002

87%

, n=1

,083

91%

, n=1

,045

85%

, n=1

,224

82%

, n=9

79

83%

, n=8

85

81%

, n=9

31

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percent Target

Page A24


Action Plan



The trend is going in the right direction as we decreased physician initial assement (PIA) time over the last 4 months.

Indicator 90th percentile physician initial assessment time - General CampusStrategic Direction Our Patients


Time Frame March 2011Source NACRS

Definition90th percentile time wait for the physician initial assessment (PIA) for patients at General Campus Emergency Department.

CHART PLACEHOLDER

TargetCELHIN Target - 4:06, lower value is desired.

Risk Ratingn/a

Analysis

Current StatusRAZ dedicated physician shift to be implemented in October 2011 Dr. T.Chan Currently recruiting, interviewing and preparing for

appointment for October 2011



4:48

, n=4

,652

4:45

, n=4

,761

4:29

, n=4

,425

4:50

, n=4

,316

4:40

, n=4

,050

4:00

, n=4

,638

4:24

, n=4

,397

4:26

, n=4

,703

4:03

, n=4

,543

3:56

, n=4

,828

4:01

, n=4

,765

3:52

, n=4

,626

3:53

, n=4

,626

3:47

, n=4

,412 5:00

, n=5

,083

4:41

, n=4

,764

4:35

, n=4

,339

4:21

, n=4

,911

0:00

1:00

2:00

3:00

4:00

5:00

6:00

Initial Assessment Time Target

Page A25


Action Plan



Indicator 90th percentile physician initial assessment time - Birchmount CampusStrategic Direction Our PatientsTime Frame March 2011Source NACRS

Definition90th percentile time wait for the physician initial assessment (PIA) for patients at Birchmount Campus Emergency Department.

CHART PLACEHOLDER


TargetCELHIN Target - 3:48, lower value is desired.

Risk Ratingn/a

Analysis


Successfully meeting this target on a regular basis.

Date Initiatedn/a


4:30

, n=3

,428

4:36

, n=3

,632

3:46

, n=3

,312

3:59

, n=3

,315

3:52

, n=3

,022

3:56

, n=3

,532

3:28

, n=3

,347

3:38

, n=3

,770

3:35

, n=3

,518

3:34

, n=3

,676

3:39

, n=3

,728

3:15

, n=3

,370

2:54

, n=3

,324

2:48

, n=3

,158

3:16

, n=4

,134

3:27

, n=3

,707

3:06

, n=3

,219

3:40

, n=3

,733

1:00

2:00

3:00

4:00

5:00

6:00

Initial Assessment Time Target

Page A26


Action Plan




Source

Analysis

May-11

Time Frame Q4 2010/11

Indicator QIP - 90th Percentile ER Lengh of Stay for Admitted Patients

Current StatusMobile Admission Team (MAT) to be implemented June 2011 N.Veloso, A.MacKinnon Funding approved by CELHIN April 2011; post position


Date Initiated

Significance90th percentile LOS is suggested indicator Ministry of Health uses to evaluate hospital as part of Excellent Care For All Act (ECFAA).



NACRS

Risk RatingHigh - There will be reputational impact of dissatisfied patients waiting in Emergency Department.

Definition90th percentile ER length of stay for admitted patients, measured from registration to leaving Emergency Department.

CHART PLACEHOLDER

QIP use percentile for Q3 2010/11. 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.


Jun-11





Apr-11

Apr-11

Apr-11

32:4

5, n

=4,3

95

29:2

5, n

=3,9

41

36:4

3, n

=4,6

57

44:1

4, n

=6,1

74

0:00

4:00

8:00

12:00

16:00

20:00

24:00

28:00

32:00

36:00

40:00

44:00

48:00

52:00

56:00

60:00

64:00

68:00

Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11

TSH 90th Percentile Target QIP Reported Value=36:43 TSH Median TSH Average

Page A27


Action Plan



Indicator QIP - 90th Percentile ER Length of Stay for Complex Condition Patients

QIP use 90th percentile value for Q3 2010/11. There 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.

NACRS

Risk Ratingn/a

Definition90th percentile ER length of stay for non-admitted patients with triage levels 1 to 3, measured from registration to leaving Emergency Department.

CHART PLACEHOLDER

Source



Apr-11

Apr-11

Apr-11Patient Flow and Access Steering Committee implemented by June 30, 2011 A.MacKinnon

Significance90th percentile LOS is suggested indicator Ministry of Health uses to evaluate hospital as part of Excellent Care For All Act (ECFAA).

Analysis

Jun-11

May-11Date InitiatedSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current Status

Mobile Admission Team (MAT) to be implemented June 2011 N.Veloso, A.MacKinnon Funding approved by CELHIN April 2011; post position by May 2011 with interview and hire June 2011

Developing terms of reference by June 2011; site visit to Sunnybrook May 2011; hire manager of patient flow and access June 2011


MAT ensure available bed ready (ABR) to in-patient unit transfer time of 45 minutes MAT Not meeting target currently, as MAT develops will Admitted Mental Health patients to in-patient bed within 8 hours by September 2011 S.Engels,

A.MacKinnonImplementing role change for Crisis Team – from consultant to patient flow coordinator

8:51

, n=1

2,32

2

8:17

, n=1

3,35

7

8:19

, n=1

4,17

1

8:01

, n=1

4,40

1

0:00

1:00

2:00

3:00

4:00

5:00

6:00

7:00

8:00

9:00

10:00

11:00

12:00

Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11

TSH 90th Percentile Target QIP Reported Value=8:19 TSH Median TSH Average

Page A28


Action Plan

Source

CHART PLACEHOLDER

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

TargetMOHLTC Target - 182, lower value is desired.

Risk Ratingn/a

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

Analysis

MOHLTC Wait Times Website / CCO Iport

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.



Indicator Wait Time - General Surgery

Time Frame Q4 2010Strategic Direction Our Patients


Date Initiated

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

76, n

=534

-

20

40

60

80

100

120

140

160

180

200

TSH 90th Percentile Ontario Target TSH Median TSH Average

Page A29


Action Plan

Source

Date Initiatedn/a


CHART PLACEHOLDER



Risk Ratingn/a

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




Indicator Wait Time - Cancer Surgery Strategic Direction Our PatientsTime Frame Q4 2010


43, n

=100

46, n

=159 60

, n=2

17

53, n

=234

50, n

=169

59, n

=192 74

, n=2

23

49, n

=221

57, n

=191

54, n

=173

53, n

=220

-

10

20

30

40

50

60

70

80

90

100


Page A30


Action Plan

n/a



Risk RatingLow - Due to the lack of funding, TSH may not meet Ontario wait time target for cataracts. This may have a reputational, financial and operational risk to the program; however, TSH is meeting or exceeding wait times in all other areas.

AnalysisThe wait time for cataract surgery has increased between April to December 2010 above the provincial target. This 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 positively impacted Q4's wait time.

Date InitiatedSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead



Indicator Wait Time - Cataract SurgeryStrategic Direction Our Patients


Q4 2010Source MOHLTC Wait Times Website / CCO IportTime Frame


CHART PLACEHOLDER

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

225,

n=1

310

120,

n=2

035

-

50

100

150

200

250

300


Page A31


Action Plan

Source

Date Initiatedn/a


CHART PLACEHOLDER



Risk Ratingn/a

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




Indicator Wait Time - Total Hip ReplacementStrategic Direction Our PatientsTime Frame Q4 2010


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

131,

n=6

5

-

50

100

150

200

250

TSH 90th Percentile Ontario Target

TSH Median TSH Average

Page A32


Action Plan

Source

Date Initiatedn/a


CHART PLACEHOLDER



Risk Ratingn/a

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




Indicator Wait Time - Total Knee ReplacementStrategic Direction Our PatientsTime Frame Q4 2010


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

108,

n=2

30

-

50

100

150

200

250

TSH 90th Percentile Ontario Target

TSH Median TSH Average

Page A33


Action Plan

n/a

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


Risk Ratingn/a

AnalysisReduction 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.

Date InitiatedSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead



Indicator Wait Time - CTStrategic Direction Our Patients



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

CHART PLACEHOLDER

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

19, n

=543

5

-

10

20

30

40

50


Page A34


Action PlanSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead

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

AnalysisMOHLTC target for priority 4 cases is 28 days and the CELHIN has a target of 65 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.

Current Status



Indicator Wait Time - MRIStrategic Direction Our Patients

Increase TSH MRI service by 2080 hrs/yr with 2nd MRI unit, slated for opening September 2011 at the Birchmount Campus. RFP issued/responses received/evaluation completed.Contract award projected June 2011

T.Jackson Currently in progress


Dec-10

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

Date Initiated

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

97, n

=294

1

-

20

40

60

80

100

120

140

160

180


Page A35


Action Plan

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

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

Date InitiatedSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current Status

Analysis

CHART PLACEHOLDER

QIP use average for most recent 12 month period (November 2009 to October 2010). TSH Emergency Department satisfaction score is above the target. It is recognized that the identified target is low. Action plans are being developed to consistently increase ED patient satisfaction. TSH has made positive changes such as Code of Conduct, and faster response time to patient complaint by Patient Relations department.



Indicator QIP - Patient satisfaction - Overall Impression: Emergency Department

n/aIndicator meeting or exceeding target, no action plan required n/a n/a

Risk Ratingn/a


Source NRC Picker

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

Time Frame Q4 2010/11 (Jan)

41.5

n=1

35

46.8

n=1

54

48.3

n=1

43

44.3

n=2

12

49.5

n=1

94

46.7

n=1

95

54.5

n=2

2

0

20

40

60

80

100

ED Score Target - GTA ED Avg QIP ED Value Reported=60.4

Page A36


Action Plan

Hospitalist Program: The implementation of the hospitalist program on 2 inpatient units at the General campus will improve patient satisfaction on dimensions related to physician availability and communication to meet and surpass GTA targets on a quarterly basis

N. Veloso, Dr. Lukowski, Dr. Clasky

Sep-10 Ongoing, Hospitalist scorecard and quarterly performance meetings

GAIN Clinic: The GAIN clinic will promote better outcomes for frail seniors by providing outpatient geriatric assessment and intervention service to meet regional targets on a quarterly basis

D. Driver, N.Veloso Jan-10 Ongoing, GAIN Scorecard and biweekly regional performance monitoring meetings

Senior Friendly Philosophy: All inpatient and outpatient services to implement Senior Friendly best practices and environmental improvements in accordance with RGP (Regional Geriatric Program) guidelines by 2011/12

N. Veloso, T. Bowers Mar-10 Assessment of current status to develop implementation plans

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current Status

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

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


Analysis

Time Frame Q4 2010/11 (Jan)Source NRC Picker

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

CHART PLACEHOLDER

QIP use average for most recent 12 month period (November 2009 to October 2010). 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.



Indicator QIP - Patient satisfaction - Overall Impression: In-patientsStrategic Direction Our Patients

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

66.3

n=3

20

59.2

n=1

30

0

20

40

60

80

100

Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11 (Jan)

IP Score Target - GTA IP Avg QIP IP Value Reported=60.4

Page A37

Patient Rounding Practices: The introduction of weekly inpatient rounding practices to promote direct communication with patients and families for quality improvement opportunities will improve patient satisfaction scores related to communication and patient experience to meet GTA targets on a quarterly basis

T. Early, A. Visva Apr-11 Implementation on one inpatient unit - 4D Birchmount. Spread to other inpatient units over 2011/12 and embedded in unit level scorecards

VALUE Program: The introduction of the VALUE (Volunteers Assisting the Leisure Unique needs of the Elderly) on CP1 would promote the stimulation and communication with patients to promote a positive patient experience as indicated by the NRC picker data to meet GTA targets in 2011/12

M. DePaulsen Apr-11 Implementation in progress

Page A38


Action Plan

Risk Ratingn/a

CHART PLACEHOLDER

Source Finance

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

TargetTSH Target - 0%, target value is desired.

AnalysisQIP use percent for Q3 2010/11. Q4 result of 0.04% reflects a surplus for 2010/11.

2010/11

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 QIP - Total marginStrategic Direction Our Performance

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a n/a

-2.00%

-1.50%

-1.00%

-0.50%

0.00%

0.50%

1.00%

2006/07 2007/08 2008/09 2009/10 2010/11

Total Margin Target QIP Reported Value=0.27%

Page A39


Action Plan

The provincial target for current ratio is 0.8 to 2.0, however, many hospitals including TSH are below this target due to accumulated operating deficits and unfunded capital expenditures.

Time Frame 2010/11Source Finance

DefinitionCalculated by dividing current assets by current liabilities. A value of less than 1.0 (100%) indicates that the current assets are less than current liabilities. The Hospital Accountability Agreement uses a variation: current assets/current liabiities less deferred contribution and this is the one that is shown below.

CHART PLACEHOLDER

SignificanceTo assess the Hospital's ability to pay its short-term obligations.

TargetTSH Target - 0.39, higher value is desired.

Risk RatingMedium- Reputational, financial or operational risk.

Analysis

Strategic Direction Our Performance



Indicator Current Ratio

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusQuarterly review by Senior Management Team to ensure a current ratio of 0.39 or better is maintained

R. Anstey In progress, on a quarterly basisJul-10Date Initiated

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

2007/08 2008/09 2009/10 2010/11

Current Ratio Target

Page A40


Action Plan

We are currently below target.


DefinitionWeighted Cases is the sum of the Resource Intensity Weight (RIW) of each case. Patients with higher weighting are expected to require more resources. This is also seen as a proxy for complexity of cases.

CHART PLACEHOLDER

SignificanceTo track our volumes of weighted cases to ensure that we are meeting our MOHLTC commitments.

TargetMOHLTC Target - 40,712, target value is desired.

Risk Ratingn/a

Analysis




Indicator Total weighted cases (Inpatient and Day Surgery)


Date Initiated

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

2007/08 2008/09 2009/10 2010/11

Weighted Cases Target

Page A41


Action Plan

We are currently above target.


DefinitionActual Mental Health Inpatient Days.

CHART PLACEHOLDER

SignificanceTo track our volumes of mental health inpatient days to ensure that we are meeting our MOHLTC commitments.


Risk Ratingn/a

Analysis




Indicator Mental Health Patient Days


Date Initiated

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

2007/08 2008/09 2009/10 2010/11

Mental Health Patient Days Target

Page A42


Action Plan

We are currently below target.


DefinitionActual Rehabilitation Inpatient Days.

CHART PLACEHOLDER

SignificanceTo track our volumes of rehabiliation inpatient days to ensure that we are meeting our MOH commitments.


Risk RatingMedium- Reputational, financial or operational risk.

Analysis




Indicator Rehab Patient Days

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusNegotiated with LHIN to reduce target for 2011/12 that reflects current practices A. Ralph CompletedMar-11

Date Initiated

0

1,000

2,000

3,000

4,000

5,000

6,000

2007/08 2008/09 2009/10 2010/11

Rehab Patient Days Target

Page A43


Action Plan

We are currently above target. Over the last few years, most of of the growth was at the Birchmount Campus.


DefinitionTotal Emergency Department (ED) visits reports the volume of patients who are registered in the ED and is indicative of the demand on the ED frm the community.

CHART PLACEHOLDER

SignificanceTo track ED visits to measure against our MOHLTC commitment


Risk Ratingn/a

Analysis




Indicator Emergency Visits


Date Initiated

0

20,000

40,000

60,000

80,000

100,000

120,000

2007/08 2008/09 2009/10 2010/11

ED Visits Target

Page A44


Action Plan



DefinitionTotal ambulatory visits registered in Meditech, excluding Emergency Department.

CHART PLACEHOLDER

SignificanceTo track Ambulatory visits to measure against our MOHLTC commitment


Risk Ratingn/a

Analysis




Indicator Ambulatory Visits (excluding ER)


Date Initiated

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

2007/08 2008/09 2009/10 2010/11

Total Ambulatory (excl ED) Target

Page A45


Action Plan



DefinitionTotal hip joint replacement and knee replacement.

CHART PLACEHOLDER

SignificanceTo track volume to measure against our MOHLTC commitment


Risk Rating

Analysis




Indicator Total Hip and Knee Replacement


Date Initiated

0

200

400

600

800

1,000

1,200

1,400

1,600

2007/08 2008/09 2009/10 2010/11

Total Hip and Knee Target

Page A46


Action Plan

We are currently meeting target. In Q4, the CE LHIN allocated additional 400 cataracts to assist TSH. The additional cataract volumes have positively impacted Q4's wait time.


DefinitionTotal Cataract Surgeries.

CHART PLACEHOLDER

SignificanceTo track volume to measure against our MOHLTC commitment.


Risk Ratingn/a

Analysis




Indicator Cataract Surgeries


Date Initiated

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

2007/08 2008/09 2009/10 2010/11

Cataract Target

Page A47


Action Plan



DefinitionTotal Computed Tomography (CT) hours.

CHART PLACEHOLDER



Risk Ratingn/a

Analysis




Indicator Computed Tomography (CT)


Date Initiated

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

2007/08 2008/09 2009/10 2010/11

CT Hours Target

Page A48


Action Plan




DefinitionTotal Magnetic Resonance Imaging (MRI) hours.

CHART PLACEHOLDER


TargetMOHLTC Target - 5.657, target value is desired.

Risk Ratingn/a

Analysis




Indicator Magnetic Resonance Imaging (MRI)

Current StatusIndicator meeting or exceeding target, no action plan required n/a n/an/a

Date Initiated

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

2007/08 2008/09 2009/10 2010/11

MRI Hours Target

Page 2


Action Plan

• TSH patients continue to receive timely access to care. TSH wait time for general surgery, cataract surgery, hip/knee, CT is below the provincial average.• The wait time for MRI is above the Ontario average, however, the wait time has decreased to 97 in Q4 2010/11.• The wait time for cataract surgery has decreased in Q4 2010/11 below the provincial target. 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 positively impacted Q4's wait time.

SourceQ4 2010/11

Strategic Direction

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 increase in the number of CLI cases at the General campus. Overall, TSH is above the Ontario average. Standardization of CLI strategies across the campuses will assist in decreasing CLI cases across TSH.• There has been zero VAP cases identified at the General campus and Birchmount campus in the last quarter. Both campuses are below the Ontario average.• SSI - Antibiotics Timing - Hip/Knee: Work continues on ensuring a good process for improvement on this indicator.

DefinitionPercentage of 16 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


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

Time FrameOur Patients

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current StatusMobile Admission Team (MAT) to be implemented June 2011 N.Veloso, A.MacKinnon May-11 Funding approved by CELHIN April 2011; post position


MAT ensure available bed ready (ABR) to in-patient unit transfer time of 45 minutes MAT Jun-11 Not meeting target currently, as MAT develops will review processes and targets


Apr-11 Implementing role change for Crisis Team – from consultant to patient flow coordinator

Patient Flow and Access Steering Committee implemented by June 30, 2011 A.MacKinnon Apr-11 Developing terms of reference by June 2011; site visit to Sunnybrook May 2011; hire manager of patient flow and access June 2011

53%

, n=1

0

63%

, n=1

2

63%

, n=1

2

58%

, n=1

1

63%

, n=1

2

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 Q4 2010/11

% patient safety indicators meeting provincial targets Target

Page 3

Apr-11 Break down consultant time data to request date/time and arrival date/time by May 2011; complete root cause analysis on May data in June 2011

RAZ dedicated physician shift to be implemented in October 2011 Dr. T.Chan May-11 Currently recruiting, interviewing and preparing for appointment for October 2011

Collect and analyze data for specialist consultant time to ED by April 1, 2011 A.MacKinnon, N.Mills

Apr-10 Monthly audits

Expanded data collection to investigate higher rate of CLI in the hemodialysis population by Q2 of 2011/12

H. Clasky, R. Lovinsky, IPAC

All Rapid Assessment Zone (RAZ) patients will have an ALOS of 3.5 hours at the Birchmount Campus and 4.0 hours at the General Campus by September 2011

D.Edman, T.Reardon, N.Alli

Apr-11 1. Implemented an elite RAZ team April 20112. Hours of operation changed from 12 hours to 24 hours May 2011

Mar-11 Data collection in progress


E.Laine, S.Vellani May-11 1. Program approved by CE LHIN April 20112. Implementation team struck May 2011

Increase TSH MRI service by 2080 hrs/yr with 2nd MRI unit, slated for opening September 2011 at the Birchmount Campus. RFP issued/responses received/evaluation completed.Contract award projected June 2011

T.Jackson Dec-10 Currently in progress

Ongoing monthly monitoring of insertion and maintenance Bundle with compliance of 90%

H. Clasky, D. Rose, P. Tamlin, R. Lovinsky, C.

Page 4


Action Plan

Time FrameSource

n/aDate InitiatedSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead


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


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

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.

403

467

576

521

626

705 73

0 768

0

100

200

300

400

500

600

700

800

900

Q1 Q2 Q3 Q4

2009/10 2010/11 Target

Page 5


Action Plan

We are currently meeting our target for this fiscal year.

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current StatusIndicator meeting or exceeding target, no action plan required n/a n/a n/a

Time Frame 2010/11Source Internal Tracking

DefinitionThe number of staff and physicians who have been trained in programs that advance our Mission, Vision and Values defined behaviours.

CHART PLACEHOLDER

SignificanceTo improve patient care and quality of service. To support alignment of staff and physicians with hospital strategies.

TargetInternal Target - 75%, higher value is desired.

Risk Ratingn/a

Analysis


Indicator Percentage of staff and physicians trained in Mission, Vision and Values defined behavioursStrategic Direction Our People

79%

, n=2

657

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010/11

% of Staff and Physicians trained Target

Page 6


Action Plan

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

AnalysisAll 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.

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

Risk Ratingn/a

Date InitiatedC. Hill

2010/11Time FrameSource NRC Picker

CHART PLACEHOLDER


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.

Scheduled for Fall 2011Current Status

Fall 2011Introduce Pulse Survey to measure engagement on a quarterly basis by Q3 2011/12

Strategic Direction


Indicator Employee Satisfaction survey results (Commitment composite score)Our People

37.5

%, n

=160

6 50.9

%, n

=159

0

0%

10%

20%

30%

40%

50%

60%

70%

2008/09 2010/11

Commitment Score Target

Page 7


Action Plan


Indicator Physician Satisfaction survey results (Commitment composite score)

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 PeopleStrategic Direction

Apr-11

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

Apr-11Date Initiated

Source NRC Picker

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current StatusUpdate performance appraisals by aligning with code of conduct and implement 25% by Q4 2011/12

Dr. S. Jackson In progress, updating performance review

Development of robust communication plan with family physicians by Q4 2011/12 Dr. S. Jackson In progress, planning initiated

The development of Physician leadership award by Q3 2011/12 Dr. S. Jackson In progress, planning initiatedApr-11

28.8

%, n

=141

42.7

%, n

=151

0%

10%

20%

30%

40%

50%

60%

2008/09 2010/11

Commitment Score Target

Page 8


Action Plan

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


Risk Ratingn/a

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

n/aDate InitiatedSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead


Indicator Percentage of defined Model of Care positions transitioned

Source Internal Tracking


Strategic Direction Our PeopleTime Frame 2010/11

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

100%

, n=2

1

0%

20%

40%

60%

80%

100%

120%

140%

2010/11

% positions transitioned Target

Page 9


Action PlanCurrent Status

Developing a strategy to improve the particiaption in performance discussions by Q1 2011/12

C.Hill In progressDate InitiatedMay-11


2010/11Source MediHR

DefinitionPercentage of leaders with completed annual performance evaluations. Percentage based on total number of non-union management positions in the hospital.

CHART PLACEHOLDER


Risk Ratingn/a

Analysis


We are currently below target for this fiscal year. Further discussion is required to identify learning gaps.

Indicator Percentage of leaders with completed performance evaluationsStrategic Direction Our People

SignificanceEmployee evaluation is important for leaders to be aware of development needs.

Time Frame

21%

, n=2

3

0%

10%

20%

30%

40%

50%

60%

2010/11

% Leaders with completed evaluation Target

Page 10


Action Plan

n/aSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead

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


Risk Ratingn/a

AnalysisPerformance evaluations are completed for the fiscal year.

Date Initiated


Indicator Percentage of Medical Directors with completed performance evaluations

Source Internal Tracking


Strategic Direction Our PeopleTime Frame Q4 2010/11

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

CHART PLACEHOLDER

80%

, n=8

100%

, n=1

0

0%

20%

40%

60%

80%

100%

120%

140%

Q3 2010/11 Q4 2010/11

% Medical Directors with completed evaluation Target

Page 11


Action Plan

We are currently below target for this fiscal year. Further discussion is required to identify learning gaps.

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current StatusDeveloping a strategy to improve the particiaption in performance discussions by Q1 2011/12

C.Hill May-11 In progress

Time Frame 2010/11Source MediHR

DefinitionPercentage of non-unionized staff with completed annual performance evaluations. Percentage based on total number of non-union positions in the hospital.

CHART PLACEHOLDER



Risk Ratingn/a

Analysis


Indicator Percentage of non-unionized staff with completed performance evaluationsStrategic Direction Our People

46%

, n=1

85

0%

10%

20%

30%

40%

50%

60%

2010/11

% Non-unionized with completed evaluation Target

Page 12


Action Plan


Indicator Percentage of unionized staff with completed performance evaluationsStrategic Direction Our PeopleTime Frame 2010/11Source MediHR

DefinitionPercentage of unionized staff with completed annual performance evaluations. Percentage based on total number of union positions in the hospital.

CHART PLACEHOLDER



Risk Ratingn/a

AnalysisWe are currently below target for this fiscal year. Further discussion is required to identify learning gaps.

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current StatusDeveloping a strategy to improve the particiaption in performance discussions by Q1 2011/12

C.Hill May-11 In progress

5%, n

=122

0%

5%

10%

15%

20%

25%

30%

35%

2010/11

% Unionized with completed evaluation Target

Page 13


Action Plan


Indicator Percentage of leaders educated in LEAN methodologyStrategic Direction Our PeopleTime Frame 2010/11Source Internal Tracking

DefinitionPercentage of leaders (i.e. clinical resource leaders, managers, directors, VP's) who have received education in LEAN methodology.

CHART PLACEHOLDER

SignificanceLEAN is the management philosophy that TSH is implementing over the next year. In order to successfully lead the clinical teams it is necessary that 100% of organizational Leaders be trained in LEAN methods.


Risk Ratingn/a

AnalysisCurrently, 17% of leaders are trained in LEAN methodology. There is a training plan for the next 3-6 months that will ensure that TSH reaches it's target of 100%.

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current StatusImplement LEAN training plan for leaders. Complete LEAN training by December 2011

TBD Apr-11 In progress, an RFP will be issued within the next fiscal quarter to select the vendor who will complete this training

17%

, n=9

0

0%

20%

40%

60%

80%

100%

120%

2010/11

% Leaders educated in LEAN Target

Page 14


Action PlanSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current Status

Feb-11Date Initiated

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

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

Time FrameSource

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

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

Expedite acquisition of major pieces of equipment included in 2011/12 Capital Plan by Q4

R. Anstey There is a delay in acquisition of new equipment (i.e. CTs)

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


IndicatorStrategic Direction

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-Dec)

% of equipment cost to total expense Target

Page 15


Action Plan

Analysis

Date Initiated

Majority of missed Q4 milestones were Business Case presentations to leadership, which was scheduled on project plans to occur in February. The meeting occurred on March 7, with six Business Case presentations and three selected to move forward.

CHART PLACEHOLDER

SignificanceA measure of department performance, efficiency and planning.

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Current Status

Our Programs, Plans, and PartnersQ4 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 RatingLow - Impact would be operational (i.e. quality).

J. Cox Ongoing, part of PMO normal operational accountability


Indicator Percentage of PMO project milestones metStrategic DirectionTime FrameSource

PMO developing categorization of reasons for missing milestones in order to identify root cause by June 30, 2011

J. Cox In progress, proposed categorization will be presented to and approved by PMO Advisory Committee in June 2011

Apr-11

Oct-10

Inventory of task timelines being development to guide future project plans (e.g. RFP development and positing, contract negotiation, hardware procurement) on a monthly bases

J. Cox In progress, as project tasks are completed- time to complete these tasks are added to the inventory. These average times are used for new project schedules

Oct-10

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 as project schedules are developed for each phase

94%

, n=1

5

96%

, n=2

2

47%

, n=2

0

40%

, n=2

1

0%

20%

40%

60%

80%

100%

120%

Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11

% milestones achieved Target

Page 16


Action PlanSMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current Status


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.

Q4 2010/11Time FrameSource

Analysis


CHART PLACEHOLDER


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

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.).

Performance & Decision Support

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

Performance and Decision Support will assess consultants workload by July 2011 to determine feasibility of taking on VP's Balanced Scorecards.

A. Damji Jun-11 Initial workload analysis completed. Awaiting results from initiative one to determine how many additional VP/ED Scorecards will be required.

Determine which VP's, if any, will submit a quarterly Balanced Scorecard by June 2011

C. Flemming May-11 PVP meets weekly. Discussion will be on next agenda

85%

, n=1

7

75%

, n=1

5

75%

, n=1

5

65%

, n=1

3

0%

20%

40%

60%

80%

100%

120%

Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11

% of posted scorecards Target

Page 17


Action Plan

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

Our Performance

FinanceSource

CHART PLACEHOLDER

AnalysisIn Q4, 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.

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.


Indicator Percentage of accountability agreement indicators achieved

Time FrameStrategic Direction

Q4 2010/11

SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current StatusIndicator meeting or exceeding target, no action plan required n/a n/an/a

75%

, n=6

100%

, n=8

88%

, n=7

75%

, n=6 88

%, n

=7

88%

, n=7

88%

, n=7

0%

20%

40%

60%

80%

100%

120%

140%

2007/08 2008/09 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11

% accountability agreement indicators achieved Target

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Tsh scorecard corporate - 2010 11 q4[1]

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