Tsh scorecard corporate - 2010 11 q3 b

The Scarborough Hospital
Corporate Balanced Scorecard
Q3 2010/11

Our 1st Priority 1st Qtr Current Previous Current Risk
Strategic Direction (to 30-Jun-11) Indicator Reported Value Value Target Status Rating* Page
Our Patients: Patient satisfaction - Overall Impression:
Create an environment of patient safety that ● ED: Would you recommend TSH for Emergency Department services? 49.1 49.7 50 R H 2
exceeds our patients' highest expectations
and delivers care that is patient and family ● IP: Would you recommend TSH for an In-patient stay? 67.2 61.9 73 Y n/a 2
driven. Percentage of publicly reported patient safety indicators meeting the provincial target (see addendum) 63% 58% 100% Y n/a 4
Number of incident reports completed (medication and non-medication) 743 730 490 G n/a 6
Hospital Standardized Mortality Ratio (HSMR) 74 84 100 G n/a 7

Service Rate of hand hygiene compliance before initial patient/patient environment contact 85% 92% 90% R 8
Excellence: To Rate of hand hygiene compliance after patient/patient environment contact 89% 96% 90% R 8
Our People: provide respectful Percentage of staff and physicians educated in Mission, Vision and Values defined behaviours Q4
Be the first choice for motivated, talented and responsive Staff and Physician satisfaction:
people who are inspired to deliver and
support excellent care in a diverse
service to our ● Employee Satisfaction survey results (Commitment composite score) 50.9% 37.5% 59% Y n/a 9
environment. patients and each ● Physician Satisfaction survey results (Commitment composite score) 42.7% 28.8% 43% Y n/a 10
other. Percentage of defined Model of Care positions transitioned 100% 100% G n/a 11
Performance evaluations
● Percentage of leaders with completed performance evaluations Q3 100%
● Percentage of Medical Directors with completed performance evaluations Q3 80% 100% Y n/a 12
● Percentage of non-union staff with completed performance evaluations Q3 100%
● Percentage of unionized staff with completed performance evaluations Q3 50%
Percentage of leaders educated in LEAN methodology Q4
Our Programs, Plans and HIT indicator #17, Percentage of equipment cost to total expense 5.2% 5.4% 5.9% R M 13
Partners: Q1
As a unified organization, lead the Number of standardized order sets used
2011/12
development of a coordinated plan for the
provision of care for all of Scarborough. Percentage of Clinical Service Plan (CSP) recommendations implemented Q4 100%
Our Performance: Percentage of PMO project milestones met 47% 96% 80% R M 14
Create an accountable, high performing
Percentage of Programs and Departments with performance indicator scorecards and action plans
organization that delivers measureable 75% 75% 100% Y n/a 15
results.
that are posted and updated quarterly on the Intranet
Total margin 0.30% -0.31% 0% G n/a 16
Percentage of accountability agreement indicators achieved 88% 88% 80% G n/a 17
* Risk rating only completed for indicators that are not meeting the target and have not improved over the prior reporting period

Current 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

Vision: To be recognized as Canada’s leader in providing the best healthcare for a global community.
Mission: To provide an outstanding care experience that meets the unique needs of each and every patient.
Values: I ntegrity, C ompassion, A ccountability, R espect, E xcellence

Page 1

Publicly Reported Patient Safety Indicators

Current Previous Current
Strategic Direction Indicator Value Value Target Status Risk Rating* Page
Our Patients: Emergency Department Wait Time for High Acuity Visits - General Campus 19:35 15:12 8:00 R H A1
Create an environment of 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

Vision: To be recognized as Canada’s leader in providing the best healthcare for a global community.
Mission: To provide an outstanding care experience that meets the unique needs of each and every patient.
Values: I ntegrity, C ompassion, A ccountability, R espect, E xcellence

Page Addendum


Indicator Emergency Department Wait Time for High Acuity Visits - General Campus
Strategic Direction Our Patients
Time Frame Q4 2010/11 (Jan)
Source MOHLTC Wait Times Website / NACRS

Performance Measurement Summary
Definition

19:35, n=3518
16:47, n=8517
This indicator reports the 90th Percentile Wait time for all ED Admits with CTAS 1-5 22:00

15:54, n=8051

15:48, n=8883

15:12, n=10727
15:32, n=8512
15:31, n=7938
and NonAdmits with CTAS 1-3.
20:00

13:12, n=9747
18:00
Significance 16:00
This indicator is associated with efficiency within the ED and within the hospital, as
well as with ED patient satisfaction. 14:00

12:00

Target 10:00
MOHLTC Target - 8:00, lower value is desired.
8:00 CHART PLACEHOLDER
Risk Rating 6:00
High - There will be reputational impact of dissatisfied patients waiting in Emergency
4:00
Department and potential financial risk of losing Pay-for-Results funding.
Analysis 2:00
There are challenges related to discharge processes, bed turnover times, and bed
0:00
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.

General Campus Target

Action Plan
Initiative Lead Date Initiated Status
ED PIP initiated J. Phan Sep-09 Ongoing
GEM D. Driver Oct-09 Ongoing
Charge Nurse and Triage RN Education T. Reardon Mar-10 Ongoing
Virtual CDU implemented Dr T. Chan Apr-10 Ongoing
Schedule to Demand D. Edman Jun-10 Completed
Rounding for Outcomes D. Edman Jun-10 Ongoing
Performance Huddles Leadership Team Jun-10 Ongoing
NP LTC B. Bickle Jun-10 Ongoing
ED PIP Kaizen Events S. Gilbert Aug-10 In progress
Schedule to Demand M. Tang Jan-11 Pending
Page A1


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

Definition

22:51, n=2519
This indicator reports the 90th Percentile Wait time for all ED Admits with CTAS 1-5 2:00
and NonAdmits with CTAS 1-3. 0:00

17:02, n=6387

16:45, n=6561

16:31, n=6673
22:00

15:30, n=6325

14:06, n=6668

13:36, n=6812
20:00
Significance

12:12, n=7166
This indicator is associated with efficiency within the ED and within the hospital, as 18:00
well as with ED patient satisfaction. 16:00
14:00

Target 12:00
MOHLTC Target - 8:00, lower value is desired. 10:00
CHART PLACEHOLDER
8:00
Risk Rating
High - There will be reputational impact of dissatisfied patients waiting in Emergency 6:00
Department and potential financial risk of losing Pay-for-Results funding. 4:00
Analysis 2:00
There are challenges related to specialty consultations and Diagnostic Imaging
0:00
procedures.

Birchmount Campus Target

Action Plan
Laboratory Technologists G. Bajwa Sep-09 Ongoing
GEM E. Laine Jun-09 Ongoing
NP LTC S. Vellani Jun-09 Ongoing
Charge Nurse and Triage RN Education L. Vanden Kroonenberg Mar-10 Ongoing
ED PIP initiated N. Alli, T. Osgood May-10 In progress
Rounding for Outcomes M. Tang Jun-10 Ongoing
Schedule to Demand M. Tang Jan-11 Pending
Page A2


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.

06:37, n=5220
9:00

06:07, n=5325

05:54, n=4487

05:42, n=4779
05:37, n=5477

05:31, n=1245
8:00

05:12, n=4481
Significance

04:48, n=3713
well as with ED patient satisfaction.
6:00

5:00
Target
MOHLTC Target - 4:00, lower value is desired. 4:00
CHART PLACEHOLDER
3:00
Risk Rating
Analysis 1:00
There are challenges related to flow of patient treatment between major and minor
0:00
cases.

General Campus Target

Action Plan
RPN Role D. Edman Jun-09 Ongoing
ED PIP initiated J. Phan, N. Velosos Sep-09 Ongoing
See and Treat Model of Care ED Staff Mar-10 In progress
Kaizen Events S. Gilbert Aug-10 In progress

Page A3


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.

06:37, n=3905
9:00

06:07, n=3811

05:54, n=3271
05:37, n=3894
8:00

05:18, n=3980

05:00, n=3950

04:57, n=1188
Significance

04:30, n=3973
well as with ED patient satisfaction.
6:00

5:00
Target
4:00
MOHLTC Target - 4:00, lower value is desired.
CHART PLACEHOLDER
3:00
Risk Rating
1:00
Analysis
There are challenges related to flow of patient treatment between major and minor 0:00
cases.

Birchmount Target

Action Plan
ED PIP initiated N. Alli, T. Osgood May-10 In progress
See and Treat Model of Care ED Staff Aug-10 In progress

Page A4


Indicator Percent of CTAS 1&2 meeting 8 hour target

Definition
This indicator reports the percentage of ED patients with CTAS 1 and 2 who 100%

73%, n=1413
73%, n=1401

71%, n=4200
71%, n=3733
completed their visit (Registration to Leaving ED) within 8 hours.

71%, n=2787
70%, n=2332
69%, n=1203
69%, n=1228

69%, n=3248
69%, n=2045
68%, n=1854

68%, n=3057
68%, n=1203
90%

67%, n=1912

67%, n=3001
66%, n=3128

66%, n=1318
66%, n=1181
66%, n=1773
65%, n=1216

65%, n=2976

67%, n=855
64%, n=1795

65%, n=463
80%
Significance
To ensure adequate patient access and flow within ED and hospital. 70%

60%

50%
Target
MOHLTC Target - 90%, higher value is desired. 40%
CHART PLACEHOLDER
30%
Risk Rating
High - There will be reputational impact of dissatisfied patients waiting in Emergency 20%
Analysis 10%
0%
procedures. A Diagnostic Imaging Kaizen event is taking place to improve
Diagnostic Imaging callbacks wait times.

General Birchmount TSH Target

Action Plan
Page A5


Indicator Percent of CTAS 3 meeting 6 hour target

Definition
This indicator reports the percentage of ED patients with CTAS 3 who completed 100%

73%, n=4877

73%, n=8575
72%, n=3698
72%, n=4553
their visit (Registration to Leaving ED) within 6 hours.

70%, n=7756
90%

67%, n=3203

67%, n=1486

66%, n=2653
66%, n=1167
65%, n=3784

65%, n=6914
65%, n=3130
63%, n=2771
61%, n=5821

61%, n=2837
60%, n=6218
60%, n=3381
60%, n=3050

60%, n=3399

59%, n=6120
58%, n=2563
80%

58%, n=2721
55%, n=5167
Significance

51%, n=2604

60%

50%
Target
MOHLTC Target - 90%, higher value is desired. 40%
CHART PLACEHOLDER
Risk Rating 30%
High - There will be reputational impact of dissatisfied patients waiting in Emergency
Department and potential financial risk of losing Pay-for-Results funding. 20%

Analysis 10%
procedures. A Diagnostic Imaging Kaizen event is taking place to improve 0%
Diagnostic Imaging callbacks wait times.


Action Plan
Page A6


Indicator Percent of CTAS 4&5 meeting 4 hour target

Definition

79%, n=3600
81%, n=3253
80%, n=6853

82%, n=3101
85%, n=3438
84%, n=6539

79%, n=1965
80%, n=977
100%

76%, n=4280

76%, n=3093

78%, n=988
75%, n=3457
75%, n=7258
This indicator reports the percentage of ED patients with CTAS 4 and 5 who

74%, n=6627
74%, n=2978

73%, n=5863
73%, n=3974

73%, n=3534
72%, n=3864

71%, n=2406
71%, n=6608
completed their visit (Registration to Leaving ED) within 4 hours.

69%, n=6508

68%, n=2634
90%

66%, n=2644
80%
Significance

60%

50%
Target
40%
MOHLTC Target - 90%, higher value is desired.
CHART PLACEHOLDER
30%
Risk Rating
High - There will be reputational impact of dissatisfied patients waiting in Emergency 20%
10%
Analysis
There are challenges related to flow of patient treatment between major and minor 0%
cases. Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11
(Jan)


Action Plan
ED-PIP initiated J. Phan, N. Velosos Sep-09 Ongoing
See and Treat Model of Care ED Staff Mar-10 In progress
Kaizen Events S. Gilbert Aug-10 In progress

Page A7


Indicator Rate of Hospital Acquired C. difficile Associated Diarrhea
Time Frame March 2011
Source Surveillance and Case Finding

Definition
Overall Rate of hospital acquired C. difficile associated diarrhea. Rate is based on 0.70

0.58, n=5

0.58, n=5
total number of inpatients/patients with confirmed infection per 1000 patient-days.

0.45, n=4
0.51, n=3
0.60

0.49, n=3
0.49, n=3
0.48, n=3

0.47, n=7
0.47, n=7
0.46, n=4
0.46, n=3

0.45, n=4
Significance

0.43, n=6
0.40, n=6

0.45
To track hospital acquired C. difficile rates in order to identify and implement 0.50

0.32, n=5
0.37, n=3
0.36, n=3
infection control measures to prevent nosocomial spread of C. difficile. While C.

0.35, n=3

0.35, n=5
0.34, n=5

0.34, n=2
difficile does not usually present a big problem for reasonably healthy adults, it can

0.33, n=2
be quite serious for those who are frail or have other health challenges. 0.40

0.32
0.26, n=4
0.26, n=4

0.26, n=2
Target

0.24, n=2
0.23, n=2

0.22, n=3

0.22, n=3
0.20, n=3

0.25
Ontario Average - 0.28, lower value is desired. 0.30

0.22
0.16, n=1

0.15, n=1
0.15, n=2
CHART PLACEHOLDER

0.13, n=1

0.17
0.13, n=1
Risk Rating

0.12, n=1
0.11, n=1

0.15
Medium- Controlling the rate of infection is very important to TSH. The increase in 0.20

0.07, n=1
0.07, n=1
the rate of infection may cause some financial and reputational risk to the
organization.

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
0.10
Analysis
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

Jul 10
Jan 10

Mar 10

Jan 11

Mar 11
Nov 09

Dec 09

Nov 10

Dec 10
Oct 09

Oct 10
Feb 10

Apr 10

Sep 10

Feb 11
May 10

Jun 10

Aug 10
Birchmount Campus remains below the Ontario Average.

General Campus Birchmount Campus
TSH Ontario Average per 1,000 patient-days
TSH Rolling 12-month Average

Action Plan
Increased vigilance to IPAC guidelines around C. difficile management for both campuses and enviromental E. Lipnicki Jan-11 Ongoing
audits of units
"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 IPAC/Pharmacy Feb-11 In progress
associated with the development of C. difficile

Page A8

Tsh scorecard corporate - 2010 11 q3 b

Tsh scorecard corporate - 2010 11 q3 b

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