1. The Scarborough Hospital
Corporate Balanced Scorecard
Q4 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:
Create an environment of patient safety that Percentage of publicly reported patient safety indicators meeting the provincial target (see addendum) 63% 63% 100% Y n/a 2
exceeds our patients' highest expectations
and delivers care that is patient and family
Number of incident reports completed (medication and non-medication) 768 730 490 G n/a 4
driven. Service
Our People: Excellence: To Percentage of staff and physicians educated in Mission, Vision and Values defined behaviours Q4 79% 75% G n/a 5
Be the first choice for motivated, talented provide respectful Employee Satisfaction survey results (Commitment composite score) 50.9% 37.5% 59% Y n/a 6
people who are inspired to deliver and
and responsive Physician Satisfaction survey results (Commitment composite score) 42.7% 28.8% 43% Y n/a 7
support excellent care in a diverse
environment. service to our Percentage of defined Model of Care positions transitioned 100% 100% 100% G n/a 8
patients and each Percentage of leaders with completed performance evaluations Q4 21% 50% Y n/a 9
other. 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
Our Programs, Plans and HIT indicator #17, Percentage of equipment cost to total expense 5.2% 5.4% 5.9% R M 14
Partners:
As a unified organization, lead the Q1
Number of standardized order sets used
development of a coordinated plan for the 2011/12
provision of care for all of Scarborough. Percentage of Clinical Service Plan (CSP) recommendations implemented
Q4
100%
2011/12
Our Performance: Percentage of PMO project milestones met 40% 47% 80% R L 15
Create an accountable, high performing
Percentage of Programs and Departments with performance indicator scorecards and action plans
organization that delivers measureable 65% 75% 100% R L 16
results.
that are posted and updated quarterly on the Intranet
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

2. The Scarborough Hospital
Corporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA)
and Publicly Reported Patient Safety Indicators (PRPSI)
1st Qtr 2011/12 QIP
TSH Strategic Direction Indicator Indicator Origin QIP Dimension QIP Priority Rating Reported Current Value Previous Value 2010/11 Target Current Status Risk Rating* Target Page
1. Rate of Hospital Acquired C. difficile Associated Diarrhea (CDI) QIP / PRPSI Safety 2 0.50 0.47 0.33 R 0.28 A1
2. Rate of Central Line Infection (CLI) QIP / PRPSI Safety 1 1.48 0.00 0.79 R L 1.93 A2
3. Rate of Ventilator Associated Pneumonia (VAP) QIP / PRPSI Safety 2 0.00 0.61 1.33 G n/a 1.46 A3
Our Patients 4. Rate of hand hygiene compliance before initial patient/patient environment contact QIP Safety 2 83% 93% 90% R L 90% A4
5. Rate of hand hygiene compliance after patient/patient environment contact 90% 100% 90% G n/a A4
6. Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia PRPSI 0.00 0.00 0.02 G n/a A5
7. Rate of Hospital Acquired Vancomycin Resistant Enterococcus (VRE) Bacteraemia PRPSI 0.00 0.00 0.00 G n/a A6
8. Rate of Timely Administration of Prophylactic Antibiotics - Primary Hip PRPSI 100.0% 97.1% 96.1% G n/a A7
9. 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 A9
11. Hospital Standardized Mortality Ratio (HSMR) QIP Effectiveness 2 74 84 100 G n/a 100 A10
12. 30 day readmission rate to any facility - All tracked CMGs QIP Effectiveness 2 14.5% 14.5% 14.5% G n/a 14.5% A11
13. Percentage of ALC days QIP / HSAA Effectiveness 1 15.9% 12.2% 12.2% R H 12.2% A12
14. Emergency Department Wait Time for High Acuity Visits - General Campus PRPSI 17:02 15:12 8:00 R H A14
15. Emergency Department Wait Time for High Acuity Visits - Birchmount Campus PRPSI 20:24 12:12 8:00 R H A15
16. Emergency Department Wait Time for Low Acuity Visits - General Campus PRPSI 5:16 4:48 4:00 R H A16
17. Emergency Department Wait Time for Low Acuity Visits - Birchmount Campus PRPSI 4:55 4:30 4:00 R H A17
18. Admitted patient treated within the LOS target of less than 8 hours - General Campus P4R 30% 32% 31% R H A18
19. Admitted patient treated within the LOS target of less than 8 hours - Birchmount Campus P4R 27% 34% 36% R H A19
20. Non-admitted high acuity patients treated within their respective targets of <=8 hours - General Campus P4R 91% 90% 87% G n/a A20
21. Non-admitted high acuity patients treated within their respective targets of <=8 hours - Birchmount Campus P4R 89% 91% 90% R H A21
22. Non-admitted low acuity patients treated within their respective targets of <=4 hours - General Campus P4R 85% 81% 81% G n/a A22
23. Non-admitted low acuity patients treated within their respective targets of <=4 hours - Birchmount Campus P4R 81% 83% 77% G n/a A23
24. 90th percentile physician initial assessment time - General Campus PRPSI 4:21 4:35 4:06 Y n/a A24
25. 90th percentile physician initial assessment time - Birchmount Campus PRPSI 3:40 3:06 3:48 G n/a A25
26. 90th Percentile ER Lengh of Stay for Admitted Patients QIP / HSAA Access 1 44:14 36:43 25:00 R H 25:00 A26
27. 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 A27
28. Wait Time - General Surgery HSAA / PRPSI 76 67 182 G n/a A28
29. Wait Time - Cancer Surgery HSAA / PRPSI 53 54 84 G n/a A29
30. Wait Time - Cataract Surgery HSAA / PRPSI 120 225 182 G n/a A30
31. Wait Time - Total Hip Replacement HSAA / PRPSI 131 151 182 G n/a A31
32. Wait time - Total Knee Replacement HSAA / PRPSI 108 153 182 G n/a A32
33. Wait Time - CT HSAA / PRPSI 19 23 28 G n/a A33
34. Wait Time - MRI HSAA / PRPSI 97 116 28 Y n/a A34
35. Patient satisfaction - Overall Impression: Emergency Department QIP Patient-Centred 1 54.5 46.7 50 G n/a 50 A35
36. Patient satisfaction - Overall Impression: In-patients QIP Patient-Centred 1 59.2 66.3 70 R H 70 A36
37. Repeat Unplanned Emergency Visited within 30 Days for Mental Health Conditions HSAA Q1 2011/12
38. Repeat Unplanned Emergency Visited within 30 Days for Substance Abuse Conditions HSAA Q1 2011/12

3. 39. Total margin QIP / HSAA Effectiveness 1 0.04% -0.31% 0% G n/a 0% A38
40. Current Ratio HSAA 0.34 0.39 0.39 R M A39
41. Total weighted cases (Inpatient and Day Surgery) HSAA 42,144 43,027 40,712 G n/a A40
Our Performance 42. Mental Health Patient Days HSAA 15,970 15,425 15,000 G n/a A41
43. Rehab Patient Days HSAA 2,397 3,221 3,530 R M A42
44. Emergency Visits HSAA 103,351 99,915 98,000 G n/a A43
45. Ambulatory Visits (excluding ER) HSAA 306,954 303,662 294,773 G n/a A44
46. Total Hip and Knee Replacement HSAA 1,257 1,275 1,225 G n/a A45
47. Cataract Surgeries HSAA 5,756 5,894 5,815 R M A46
48. Computed Tomography (CT) HSAA 8,037 8,352 7,245 G n/a A47
49. Magnetic Resonance Imaging (MRI) HSAA 6,225 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
Red = Performance indicator has not met the target for the current reporting period, and has not improved over the prior reporting period Priority 1 - Highest priority
Yellow = Performance is below the target, however it has improved over the previous reporting period • Current performance below “benchmark” (if one exists) or below long term goal; significant improvements requ
Green = Performance indicator has met or exceeded or is not statistically different than the performance target for the current reporting period • Aligned with organizational priorities/strategic plan, defined accreditation priority or recommendation, funding
tied to initiative, aligned with government agenda
Risk Rating Legend Priority 2 - Moderate priority:
L = Low reputational, financial or operational risk • Current performance just below “benchmark” (if one exists) or below long term goal; room for improvement
M = Medium reputational, financial or operational risk • Aligned with organizational priorities/strategic plan, defined accreditation priority or recommendation, funding
H = High reputational, financial or operational risk tied to initiative, aligned with government agenda
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.
Values: I ntegrity, C ompassion, A ccountability, R espect, E xcellence

4. The Scarborough Hospital
Corporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA)
and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator QIP - Rate of Hospital Acquired C. difficile Associated Diarrhea
Strategic Direction Our Patients
Time Frame June 2011
Source Surveillance and Case Finding
Performance Measurement Summary
Definition
1.20
1.09, n=9
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.
0.85, n=5
1.00
0.78, n=11
Significance
To track hospital acquired C. difficile rates in order to identify and implement
infection control measures to prevent nosocomial spread of C.difficile. While C. 0.80
0.58, n=5
0.58, n=5
difficile does not usually present a big problem for reasonably healthy adults, it can
0.53, n=5
0.51, n=3
0.50, n=7
0.49, n=3
0.49, n=3
be quite serious for those who are frail or have other health challenges.
0.48, n=4
0.47, n=7
0.47, n=7
0.47, n=7
0.47, n=3
0.46, n=4
0.45, n=4
0.45, n=4
0.43, n=6
C. difficile is communicable. It can live in the environment and on other surfaces. 0.60
0.38, n=6
0.37, n=3
0.36, n=3
Rigorous cleaning regimes, patient isolation and hand washing are some of the
0.35, n=5
0.34, n=2
0.34, n=5
0.34, n=2
0.33, n=2
0.32, n=5
strategies used to combat C. difficile.
0.26, n=4
0.26, n=2
0.25, n=2
0.25, n=2
0.24, n=2
0.23, n=2
0.22, n=3
0.22, n=3
0.22, n=3
0.40 CHART PLACEHOLDER
0.20, n=3
Target
0.17, n=1
0.16, n=1
0.15, n=1
0.15, n=1
0.15, n=2
Ontario Average - 0.33, lower value is desired.
0.13, n=1
0.13, n=1
0.07, n=1
Risk Rating
0.20
0.00, n=0
0.00, n=0
0.00, n=0
0.00, n=0
0.00, n=0
n/a
Analysis -
QIP use rate for January to December 2010. There have been a few months of
Jul 10
Mar 10
Nov 10
Dec 10
Jan 11
Mar 11
Oct 10
Feb 10
Apr 10
May 10
Aug 10
Sep 10
Feb 11
Apr 11
May 11
Jun 10
Jun 11
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 General Campus Birchmount Campus
Ontario Average. TSH Ontario Average per 1,000 patient-days
TSH Rolling 12-month Average QIP Reported Value=0.26
Action Plan
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current Status
Indicator meeting or exceeding target, no action plan required n/a n/a n/a
Page A1

5. The Scarborough Hospital
Corporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA)
and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator QIP - Rate of Central Line Infection (CLI)
Strategic Direction Our Patients
Time Frame Q1 2011/12
Source Surveillance and Case Finding
Performance Measurement Summary
Definition
Overall rate of hospital acquired Central Line Infection. Rate is based on total 8.00
6.32, n=6
number of CLI incidents diagnosed after two days of Critical Care admission per
1000 patient days. 7.00
4.98, n=5
Significance 6.00
4.58, n=6
To track hospital acquired CLI rates in order to identify and implement necessary
3.90, n=6
prevention plans to reduce the risk of infection from spreading. 5.00
4.00
2.54, n=1
2.36, n=1
2.31, n=3
Target
2.21, n=2
2.06, n=3
Ontario Average - 0.79, lower value is desired.
1.87, n=1
3.00 CHART PLACEHOLDER
1.48, n=3
Risk Rating
0.78, n=1
2.00
0.69, n=1
0.62, n=1
Low - 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.
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
1.00
Analysis
QIP 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 0.00
strategies to standardize processes across the campuses is showing improvements Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11 Q1 2011/12
in the rates. There is lower rate of infection associated with PICC, therefore the use
of PICC has been increased. General Campus Birchmount Campus
TSH Ontario Average per 1,000 patient-days
TSH Rolling 12-month Average QIP Reported Value=1.76
Action Plan
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current Status
Monthly monitoring of insertions and maintenance Bundle which includes hand H. Clasky, D. Rose, P. Apr-10 Monthly audits
hygiene, maximal barrier precautions, and chlorhexidine skin antisepsis and optimal Tamlin, R. Lovinsky, C.
catheter side selection to adhere the compliance of 90% to decrease rate of CLI for Shelton
the next quarter
Expanded data collection to include the program that the hemodialysis patients are H. Clasky, R. Lovinsky, Mar-11 Data collection in progress
coming from, type of line being used, and CLI reduction interventions such as the IPAC
use of chlorhexidine dressing and bath to investigate higher rate of CLI in the
hemodialysis population by Q2 of 2011/12
Page A2

6. Page A2

7. The Scarborough Hospital
Corporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA)
and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator QIP - Rate of Ventilator Associated Pneumonia (VAP)
Strategic Direction Our Patients
Time Frame Q1 2011/12
Source Surveillance and Case Finding
Performance Measurement Summary
Definition
Overall Rate of hospital acquired Ventilator Associated Pneumonia. Rate is based 7.0
on total number of VAP incidents diagnosed after two days of Critical Care
admission per 1000 patient days.
6.0
0.00, n=0
Significance
5.0
To track hospital acquired VAP rates in order to identify and implement necessary
prevention plans to reduce the risk of development of pneumonia in the ICU patient
population. 4.0
2.47, n=2
Target 3.0
1.63, n=2
Ontario Average - 1.33, lower value is desired.
1.58, n=2
1.40, n=1
1.36, n=2
CHART PLACEHOLDER
1.14, n=1
0.97, n=1
0.90, n=1
2.0
0.76, n=1
Risk Rating
n/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
4.56, n=2
0.00, n=0
0.00, n=0
0.00, n=0
0.00, n=0
2.26, n=1
1.0
Analysis
QIP use rate for January to December 2010. There were zero VAP case
0.0
identified in the Q4. Currently meeting target.
Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11
General Campus Birchmount Campus
TSH Ontario Average per 1,000 patient-days
TSH Rolling 12-month Average QIP Reported Value=1.22
Action Plan
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current Status
Indicator meeting or exceeding target, no action plan required n/a n/a n/a
Page A3

8. The Scarborough Hospital
Corporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA)
and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator QIP - Rate of hand hygiene compliance
Strategic Direction Our Patients
Time Frame Q1 2011/12
Source Surveillance and Case Finding
Performance Measurement Summary
Definition
The single most common way of transferring health care-associated infections (HAIs) 140%
in health care settings is on the hands of health care providers. Health care providers
100%, n=56
100%, n=56
100%, n=7
96%, n=392
96%, n=392
move from patient to patient and room to room while providing care and working in the
92%, n=1180
92%, n=1187
97%, n=58
96%, n=25
96%, n=25
96%, n=25
96%, n=25
120%
95%, n=57
93%, n=52
93%, n=52
93%, n=62
90%, n=301
90%, n=361
89%, n=412
patient environment. This movement provides many opportunities for the transmission
85%, n=1070
85%, n=1063
88%, n=354
87%, n=360
87%, n=360
90%, n=60
85%, n=391
84%, n=334
83%, n=330
88%, n=7
of organisms on hands that can cause infections.
81%, n=268
100%
Significance
Proper hand hygiene protects patients and providers and will reduce the spread of 80%
infections and the associated treatment costs, reduce hospital lengths of stay and
readmissions, reduce wait times, and prevent deaths.
60%
Target. CHART PLACEHOLDER
Ontario Target - 90% Before and 90% After, higher value is desired. 40%
Risk Rating
20%
0%, n=0
0%, n=0
0%, n=0
0%, n=0
0%, n=0
0%, n=0
Low- Reputational, financial or operational risk.
Analysis 0%
QIP use rate for 2009/10, only for before patient contact. Due to the lack of hand Before After Before After Before After Before After Before After Before After
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 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11
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%.
General Campus Birchmount Campus TSH Target QIP Reported Value=92.3%
Action Plan
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current Status
Development of a audit process to monitor unit based hand hygiene audits and IPAC Mar-11 In progress, on a monthly basis
program overseen by IPAC and Decision Support. Monthly audit to observe number of
times hand hygiene performed before patient contact.
Page A4

9. The Scarborough Hospital
Corporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA)
and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia
Strategic Direction Our Patients
Time Frame Q1 2011/12
Source Surveillance and Case Finding
Performance Measurement Summary
Definition 0.16
Overall Rate of hospital acquired Methicillin Resistant Staphylococcus Aureus
(MRSA) bacteraemia. Rate is based on total number of inpatients/patients with
0.14
confirmed infection per 1000 patient-days.
0.12
Significance
Higher MRSA colonization rates will lead to higher rates of blood stream infections 0.10
with MRSA. Tracking hospital acquired MRSA Bacteraemia rates helps to identify
0.06, n=1
the clinical significance of MRSA colonization. This will help identify a need for 0.08
further strategies to prevent nosocomial spread of MRSA.
0.04, n=1
0.04, n=1
0.04, n=1
0.04, n=1
Target 0.06
0.02, n=1
0.02, n=1
0.02, n=1
0.02, n=1
0.02, n=1
Ontario Average - 0.02, lower value is desired.
0.04 CHART PLACEHOLDER
Risk Rating
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
n/a
0.02
0.00
Analysis
Both General Campus and 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
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current Status
Indicator meeting or exceeding target, no action plan required n/a n/a n/a
Page A5

10. The Scarborough Hospital
Corporate Balanced Scorecard
Quality Improvement Plan (QIP), Hospital Services Accountability Agreement (HSAA)
and Publicly Reported Patient Safety Indicators (PRPSI)
Indicator Rate of Hospital Acquired Vancomycin Resistant Enterococcus (VRE) Bacteraemia
Strategic Direction Our Patients
Time Frame Q1 2011/12
Source Surveillance and Case Finding
Performance Measurement Summary
Definition
Overall Rate of hospital acquired Vancomycin Resistant Enterococcus (VRE) 0.012
bacteraemia. Rate is based on total number of inpatients/patients with confirmed
infection per 1000 patient-days.
0.010
Significance
To track hospital acquired VRE bacteraemia rates in order to identify and implement 0.008
necessary prevention plans to reduce the risk of infection from spreading.
0.006
Target
0.004
Ontario Average - 0.00, lower value is desired.
CHART PLACEHOLDER
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
Risk Rating 0.002
n/a
0.000
Analysis
There have been no reportable cases of VRE bacteraemia despite increased
numbers of VRE colonized patients since April 2010.
General Campus Birchmount Campus
TSH Ontario Average per 1,000 patient-days
TSH Rolling 12-month Average
Action Plan
SMART Initiative (Specific, Measureable, Attainable, Realistic, Time-Bound) Lead Date Initiated Current Status
Indicator meeting or exceeding target, no action plan required n/a n/a n/a
Page A6