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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
The Scarborough Hospital
                                                                                                                      Corporate Balanced Scorecard
                                                                                                                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
                                                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
The Scarborough Hospital
                                                                         Corporate Balanced Scorecard
                                                                   Publicly Reported Patient Safety Indicators

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
Department and potential financial risk of losing Pay-for-Results funding.                4:00

Analysis                                                                                  2:00
There are challenges related to discharge processes, bed turnover times, and bed
availability. As a result of ED PIP, white boards, discharge huddles, patient             0:00
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
The Scarborough Hospital
                                                                         Corporate Balanced Scorecard
                                                                   Publicly Reported Patient Safety Indicators

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

Performance Measurement Summary
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
                                                                                         20:00




                                                                                                                                                                                                              13:36, n=6812
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
Initiative                                                                                                              Lead                                                  Date Initiated                                  Status
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
Virtual CDU implemented                                                                                                 Dr T. Chan                                            Apr-10                                          Ongoing
ED PIP initiated                                                                                                        N. Alli, T. Osgood                                    May-10                                          In progress
Rounding for Outcomes                                                                                                   M. Tang                                               Jun-10                                          Ongoing
Performance Huddles                                                                                                     Leadership Team                                       Jun-10                                          Ongoing
Schedule to Demand                                                                                                      M. Tang                                               Jan-11                                          Pending
                                                                                                 Page A2
The Scarborough Hospital
                                                                         Corporate Balanced Scorecard
                                                                   Publicly Reported Patient Safety Indicators

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

Performance Measurement Summary
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
                                                                                         8:00




                                                                                                                                                                                                                                               05:31, n=1245
                                                                                                                                                                                                           05:12, n=4481
Significance




                                                                                                                                                                                                                               04:48, n=3713
This indicator is associated with efficiency within the ED and within the hospital, as   7:00
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
High - There will be reputational impact of dissatisfied patients waiting in Emergency   2:00
Department and potential financial risk of losing Pay-for-Results funding.
Analysis                                                                                 1:00
There are challenges related to flow of patient treatment between major and minor
                                                                                         0:00
cases.




                                                                                                                                                    General Campus                                Target



Action Plan
Initiative                                                                                                              Lead                                               Date Initiated                                  Status
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
Rounding for Outcomes                                                                                                   D. Edman                                           Jun-10                                          Ongoing
Performance Huddles                                                                                                     Leadership Team                                    Jun-10                                          Ongoing
Kaizen Events                                                                                                           S. Gilbert                                         Aug-10                                          In progress




                                                                                                Page A3
The Scarborough Hospital
                                                                         Corporate Balanced Scorecard
                                                                   Publicly Reported Patient Safety Indicators

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

Performance Measurement Summary
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
                                                                                         7:00




                                                                                                                                                                                                                   04:30, n=3973
This indicator is associated with efficiency within the ED and within the hospital, as
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
High - There will be reputational impact of dissatisfied patients waiting in Emergency   2:00
Department and potential financial risk of losing Pay-for-Results funding.
                                                                                         1:00
Analysis
There are challenges related to flow of patient treatment between major and minor        0:00
cases.




                                                                                                                                                    Birchmount                       Target



Action Plan
Initiative                                                                                                              Lead                                            Date Initiated                         Status
RPN Role                                                                                                                D. Edman                                        Jun-09                                 Ongoing
ED PIP initiated                                                                                                        N. Alli, T. Osgood                              May-10                                 In progress
Rounding for Outcomes                                                                                                   D. Edman                                        Jun-10                                 Ongoing
Performance Huddles                                                                                                     Leadership Team                                 Jun-10                                 Ongoing
See and Treat Model of Care                                                                                             ED Staff                                        Aug-10                                 In progress




                                                                                                Page A4
The Scarborough Hospital
                                                                       Corporate Balanced Scorecard
                                                                 Publicly Reported Patient Safety Indicators

Indicator                    Percent of CTAS 1&2 meeting 8 hour target
Strategic Direction          Our Patients
Time Frame                   Q4 2010/11 (Jan)
Source                       MOHLTC Wait Times Website / NACRS

Performance Measurement Summary
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=1228




                                                                                                                                                                 69%, n=1203
                                                                                                                                                                 69%, n=3248
                                                                                                                                                                 69%, n=2045
                                                                                         90%




                                                                                                                  68%, n=1854

                                                                                                                  68%, n=3057
                                                                                                                  68%, n=1203
                                                                                                    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%
Department and potential financial risk of losing Pay-for-Results funding.
Analysis                                                                                 10%
There are challenges related to specialty consultations and Diagnostic Imaging
                                                                                          0%
procedures. A Diagnostic Imaging Kaizen event is taking place to improve
Diagnostic Imaging callbacks wait times.




                                                                                                                           General               Birchmount               TSH              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
                                                                                                Page A5
The Scarborough Hospital
                                                                       Corporate Balanced Scorecard
                                                                 Publicly Reported Patient Safety Indicators

Indicator                    Percent of CTAS 3 meeting 6 hour target
Strategic Direction          Our Patients
Time Frame                   Q4 2010/11 (Jan)
Source                       MOHLTC Wait Times Website / NACRS

Performance Measurement Summary
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
                                                                                         80%




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




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




                                                                                                   51%, n=2604
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
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%
There are challenges related to specialty consultations and Diagnostic Imaging
procedures. A Diagnostic Imaging Kaizen event is taking place to improve                  0%
Diagnostic Imaging callbacks wait times.




                                                                                                                                General              Birchmount              TSH                   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
                                                                                                Page A6
The Scarborough Hospital
                                                                       Corporate Balanced Scorecard
                                                                 Publicly Reported Patient Safety Indicators

Indicator                    Percent of CTAS 4&5 meeting 4 hour target
Strategic Direction          Our Patients
Time Frame                   Q4 2010/11 (Jan)
Source                       MOHLTC Wait Times Website / NACRS

Performance Measurement Summary
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
This indicator reports the percentage of ED patients with CTAS 4 and 5 who




                                                                                                                                                        75%, n=3457
                                                                                                                     75%, n=7258




                                                                                                                                                                       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
                                                                                         90%




                                                                                                                                    68%, n=2634
                                                                                                   66%, n=2644
                                                                                         80%
Significance
To ensure adequate patient access and flow within ED and hospital.                       70%

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



                                                                                                                               General               Birchmount                  TSH                 Target



Action Plan
Initiative                                                                                                              Lead                                     Date Initiated                         Status
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
Rounding for Outcomes                                                                                                   D. Edman                                 Jun-10                                 Ongoing
Performance Huddles                                                                                                     Leadership Team                          Jun-10                                 Ongoing
Kaizen Events                                                                                                           S. Gilbert                               Aug-10                                 In progress




                                                                                                Page A7
The Scarborough Hospital
                                                                         Corporate Balanced Scorecard
                                                                   Publicly Reported Patient Safety Indicators

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

Performance Measurement Summary
Definition




                                                                                                                                                                                                                                                                      1.09, n=9
Overall Rate of hospital acquired C. difficile associated diarrhea. Rate is based on     1.20
total number of inpatients/patients with confirmed infection per 1000 patient-days.

                                                                                         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
                                                                                                                          0.43,0.51, n=3
be quite serious for those who are frail or have other health challenges.




                                                                                                                               0.49, n=3
                                                                                                                               0.49, n=3
                                                                                                                      0.35, n=3 n=3




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




                                                                                                         0.15, n=10.32, n=5 n=4
                                                                                                                            0.45, n=4
                                                                                         0.60




                                                                                                                                 n=6
Target




                                                                                                                         0.40, n=6
                                                                                                                              0.48,




                                                                                                         0.15, n=1 0.38, n=6



                                                                                                                            0.45,
                                                                                                                       0.37, n=3
                                                                                                                       0.36, n=3
Ontario Average - 0.28, lower value is desired.




                                                                                                                      0.35, n=5




                                                                                                                                                                                                                                                                         0.34, n=2
                                                                                                                     0.34, n=5




                                                                                                       0.13, n=1 0.34, n=2




                                                                                                                    0.33, n=2




                                                                                                                 0.26, n=4
                                                                                                                0.26, n=2
                                                                                                                                                       CHART PLACEHOLDER




                                                                                                           0.17, n=1 n=2
                                                                                                          0.16, n=1 n=2
                                                                                                               0.23, n=2
                                                                                         0.40




                                                                                                              0.22, n=3
                                                                                                0.00, n=0 0.22, n=3

                                                                                                             0.22, n=3
Risk Rating




                                                                                                             0.20, n=3




                                                                                                                0.25,
                                                                                                               0.24,
Medium- Controlling the rate of infection is very important to TSH. The increase in




                                                                                                        0.15, n=2
                                                                                                       0.13, n=1
                                                                                                       0.12, n=1
                                                                                                      0.11, n=1
the rate of infection may cause some financial and reputational risk to the




                                                                                                0.00, n=0 n=1
                                                                                                0.00, n=0n=1
organization.
                                                                                         0.20




                                                                                                0.00, n=0
                                                                                                0.00, n=0
                                                                                                0.00, n=0




                                                                                                0.00, n=0



                                                                                                0.00, n=0

                                                                                                0.00, n=0
                                                                                                    0.07,
                                                                                                    0.07,
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
                                                                                                 Oct 09




                                                                                                                                                                                                               Oct 10




                                                                                                                                                                                                                                                    Feb 11
                                                                                                                                     Feb 10



                                                                                                                                                       Apr 10

                                                                                                                                                                May 10




                                                                                                                                                                                             Aug 10

                                                                                                                                                                                                      Sep 10




                                                                                                                                                                                                                                                                         Apr 11
                                                                                                                                                                         Jun 10

                                                                                                                                                                                    Jul 10
                                                                                                          Nov 09

                                                                                                                   Dec 09

                                                                                                                            Jan 10



                                                                                                                                              Mar 10




                                                                                                                                                                                                                        Nov 10

                                                                                                                                                                                                                                  Dec 10

                                                                                                                                                                                                                                           Jan 11



                                                                                                                                                                                                                                                             Mar 11
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
Initiative                                                                                                                    Lead                                                Date Initiated                                 Status
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
The Scarborough Hospital
                                                                       Corporate Balanced Scorecard
                                                                 Publicly Reported Patient Safety Indicators

Indicator                   Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia
Strategic Direction         Our Patients
Time Frame                  Q4 2010/11
Source                      Surveillance and Case Finding

Performance Measurement Summary
Definition                                                                            0.06




                                                                                                                             0.00, n=0
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.                                            0.05




                                                                                                                                                                                                                          0.00, n=0
                                                                                                                                                                       0.00, n=0
                                                                                                                                               0.00, n=0
Significance
Higher MRSA colonization rates will lead to higher rates of blood stream infections   0.04
with MRSA. Tracking hospital acquired MRSA Bacteraemia rates helps to identify




                                                                                                                                                                                                                                      0.00, n=0
the clinical significance of MRSA colonization. This will help identify a need for




                                                                                                                                                           0.00, n=0



                                                                                                                                                                                   0.00, n=0
                                                                                                                                   0.00, n=0
further strategies to prevent nosocomial spread of MRSA.                              0.03

Target
Ontario Average - 0.02, lower value is desired.                                       0.02
                                                                                                                                               CHART PLACEHOLDER
Risk Rating
n/a
                                                                                      0.01




                                                                                             0.11, n=1
                                                                                             0.00, n=0
                                                                                             0.06, n=1

                                                                                                           0.00, n=0
                                                                                                           0.00, n=0
                                                                                                           0.00, n=0

                                                                                                                       0.00, n=0




                                                                                                                                                     0.00, n=0



                                                                                                                                                                             0.00, n=0


                                                                                                                                                                                               0.00, n=0
                                                                                                                                                                                               0.00, n=0
                                                                                                                                                                                               0.00, n=0

                                                                                                                                                                                                              0.00, 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
Analysis                                                                              0.00
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
Initiative                                                                                                       Lead                                                              Date Initiated                                 Status
Continue with MRSA surveillance protocols                                                                        E. Lipnicki                                                       Jul-10                                         Ongoing
Begin universal screening for MRSA colonization on admission                                                     IPAC                                                              Dec-10                                         In progress




                                                                                         Page A9
The Scarborough Hospital
                                                                      Corporate Balanced Scorecard
                                                                Publicly Reported Patient Safety Indicators

Indicator                   Rate of Hospital Acquired Vancomycin Resistant Enterococcus (VRE) Bacteraemia
Strategic Direction         Our Patients
Time Frame                  Q4 2010/11
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
Ontario Average - 0.00, lower value is desired.                                       0.004
                                                                                                                                     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
Initiative                                                                                                           Lead                              Date Initiated                      Status
VRE colonization outbreak over July 2010. Continue with IPAC protocols and ICRT recommendations for                  E. Lipnicki                       Apr-10                              Completed July 2010
surveillance and outbreak management policies
ICRT invited for third party review July 20, 2010- waiting for final recommendations                                 E. Lipnicki                       Jul-10                              Completed
Universal screening to be implemented to identify patients colonized with VRE on admission and thus reduce
nosocomial spread                                                                                                    IPAC                              Dec-10                              In progress




                                                                                              Page A10
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c
TSH Corporate Scorecard - 2010 11 q3 c

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TSH Corporate Scorecard - 2010 11 q3 c

  • 1. 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
  • 2. The Scarborough Hospital Corporate Balanced Scorecard 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 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
  • 3. The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety Indicators 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 Department and potential financial risk of losing Pay-for-Results funding. 4:00 Analysis 2:00 There are challenges related to discharge processes, bed turnover times, and bed availability. As a result of ED PIP, white boards, discharge huddles, patient 0:00 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
  • 4. The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety Indicators Indicator Emergency Department Wait Time for High Acuity Visits - Birchmount Campus Strategic Direction Our Patients Time Frame Q4 2010/11 (Jan) Source MOHLTC Wait Times Website / NACRS Performance Measurement Summary 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 20:00 13:36, n=6812 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 Initiative Lead Date Initiated Status 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 Virtual CDU implemented Dr T. Chan Apr-10 Ongoing ED PIP initiated N. Alli, T. Osgood May-10 In progress Rounding for Outcomes M. Tang Jun-10 Ongoing Performance Huddles Leadership Team Jun-10 Ongoing Schedule to Demand M. Tang Jan-11 Pending Page A2
  • 5. The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety Indicators Indicator Emergency Department Wait Time for Low Acuity Visits - General Campus Strategic Direction Our Patients Time Frame Q4 2010/11 (Jan) Source MOHLTC Wait Times Website / NACRS Performance Measurement Summary 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 8:00 05:31, n=1245 05:12, n=4481 Significance 04:48, n=3713 This indicator is associated with efficiency within the ED and within the hospital, as 7:00 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 High - There will be reputational impact of dissatisfied patients waiting in Emergency 2:00 Department and potential financial risk of losing Pay-for-Results funding. Analysis 1:00 There are challenges related to flow of patient treatment between major and minor 0:00 cases. General Campus Target Action Plan Initiative Lead Date Initiated Status 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 Rounding for Outcomes D. Edman Jun-10 Ongoing Performance Huddles Leadership Team Jun-10 Ongoing Kaizen Events S. Gilbert Aug-10 In progress Page A3
  • 6. The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety Indicators Indicator Emergency Department Wait Time for Low Acuity Visits - Birchmount Campus Strategic Direction Our Patients Time Frame Q4 2010/11 (Jan) Source MOHLTC Wait Times Website / NACRS Performance Measurement Summary 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 7:00 04:30, n=3973 This indicator is associated with efficiency within the ED and within the hospital, as 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 High - There will be reputational impact of dissatisfied patients waiting in Emergency 2:00 Department and potential financial risk of losing Pay-for-Results funding. 1:00 Analysis There are challenges related to flow of patient treatment between major and minor 0:00 cases. Birchmount Target Action Plan Initiative Lead Date Initiated Status RPN Role D. Edman Jun-09 Ongoing ED PIP initiated N. Alli, T. Osgood May-10 In progress Rounding for Outcomes D. Edman Jun-10 Ongoing Performance Huddles Leadership Team Jun-10 Ongoing See and Treat Model of Care ED Staff Aug-10 In progress Page A4
  • 7. The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety Indicators Indicator Percent of CTAS 1&2 meeting 8 hour target Strategic Direction Our Patients Time Frame Q4 2010/11 (Jan) Source MOHLTC Wait Times Website / NACRS Performance Measurement Summary 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=1228 69%, n=1203 69%, n=3248 69%, n=2045 90% 68%, n=1854 68%, n=3057 68%, n=1203 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% Department and potential financial risk of losing Pay-for-Results funding. Analysis 10% There are challenges related to specialty consultations and Diagnostic Imaging 0% procedures. A Diagnostic Imaging Kaizen event is taking place to improve Diagnostic Imaging callbacks wait times. General Birchmount TSH 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 Page A5
  • 8. The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety Indicators Indicator Percent of CTAS 3 meeting 6 hour target Strategic Direction Our Patients Time Frame Q4 2010/11 (Jan) Source MOHLTC Wait Times Website / NACRS Performance Measurement Summary 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 80% 59%, n=6120 58%, n=2563 58%, n=2721 55%, n=5167 Significance 51%, n=2604 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 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% There are challenges related to specialty consultations and Diagnostic Imaging procedures. A Diagnostic Imaging Kaizen event is taking place to improve 0% Diagnostic Imaging callbacks wait times. General Birchmount TSH 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 Page A6
  • 9. The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety Indicators Indicator Percent of CTAS 4&5 meeting 4 hour target Strategic Direction Our Patients Time Frame Q4 2010/11 (Jan) Source MOHLTC Wait Times Website / NACRS Performance Measurement Summary 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 This indicator reports the percentage of ED patients with CTAS 4 and 5 who 75%, n=3457 75%, n=7258 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 90% 68%, n=2634 66%, n=2644 80% Significance To ensure adequate patient access and flow within ED and hospital. 70% 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% Department and potential financial risk of losing Pay-for-Results funding. 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) General Birchmount TSH Target Action Plan Initiative Lead Date Initiated Status 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 Rounding for Outcomes D. Edman Jun-10 Ongoing Performance Huddles Leadership Team Jun-10 Ongoing Kaizen Events S. Gilbert Aug-10 In progress Page A7
  • 10. The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety Indicators Indicator Rate of Hospital Acquired C. difficile Associated Diarrhea Strategic Direction Our Patients Time Frame March 2011 Source Surveillance and Case Finding Performance Measurement Summary Definition 1.09, n=9 Overall Rate of hospital acquired C. difficile associated diarrhea. Rate is based on 1.20 total number of inpatients/patients with confirmed infection per 1000 patient-days. 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 0.43,0.51, n=3 be quite serious for those who are frail or have other health challenges. 0.49, n=3 0.49, n=3 0.35, n=3 n=3 0.47, n=7 0.47, n=7 0.46, n=4 0.26, n=4 0.46, n=3 0.15, n=10.32, n=5 n=4 0.45, n=4 0.60 n=6 Target 0.40, n=6 0.48, 0.15, n=1 0.38, n=6 0.45, 0.37, n=3 0.36, n=3 Ontario Average - 0.28, lower value is desired. 0.35, n=5 0.34, n=2 0.34, n=5 0.13, n=1 0.34, n=2 0.33, n=2 0.26, n=4 0.26, n=2 CHART PLACEHOLDER 0.17, n=1 n=2 0.16, n=1 n=2 0.23, n=2 0.40 0.22, n=3 0.00, n=0 0.22, n=3 0.22, n=3 Risk Rating 0.20, n=3 0.25, 0.24, Medium- Controlling the rate of infection is very important to TSH. The increase in 0.15, n=2 0.13, n=1 0.12, n=1 0.11, n=1 the rate of infection may cause some financial and reputational risk to the 0.00, n=0 n=1 0.00, n=0n=1 organization. 0.20 0.00, n=0 0.00, n=0 0.00, n=0 0.00, n=0 0.00, n=0 0.00, n=0 0.07, 0.07, 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 Oct 09 Oct 10 Feb 11 Feb 10 Apr 10 May 10 Aug 10 Sep 10 Apr 11 Jun 10 Jul 10 Nov 09 Dec 09 Jan 10 Mar 10 Nov 10 Dec 10 Jan 11 Mar 11 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 Initiative Lead Date Initiated Status 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
  • 11. The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety Indicators Indicator Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia Strategic Direction Our Patients Time Frame Q4 2010/11 Source Surveillance and Case Finding Performance Measurement Summary Definition 0.06 0.00, n=0 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. 0.05 0.00, n=0 0.00, n=0 0.00, n=0 Significance Higher MRSA colonization rates will lead to higher rates of blood stream infections 0.04 with MRSA. Tracking hospital acquired MRSA Bacteraemia rates helps to identify 0.00, n=0 the clinical significance of MRSA colonization. This will help identify a need for 0.00, n=0 0.00, n=0 0.00, n=0 further strategies to prevent nosocomial spread of MRSA. 0.03 Target Ontario Average - 0.02, lower value is desired. 0.02 CHART PLACEHOLDER Risk Rating n/a 0.01 0.11, n=1 0.00, n=0 0.06, n=1 0.00, n=0 0.00, n=0 0.00, n=0 0.00, n=0 0.00, n=0 0.00, n=0 0.00, n=0 0.00, n=0 0.00, n=0 0.00, 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 Analysis 0.00 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 Initiative Lead Date Initiated Status Continue with MRSA surveillance protocols E. Lipnicki Jul-10 Ongoing Begin universal screening for MRSA colonization on admission IPAC Dec-10 In progress Page A9
  • 12. The Scarborough Hospital Corporate Balanced Scorecard Publicly Reported Patient Safety Indicators Indicator Rate of Hospital Acquired Vancomycin Resistant Enterococcus (VRE) Bacteraemia Strategic Direction Our Patients Time Frame Q4 2010/11 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 Ontario Average - 0.00, lower value is desired. 0.004 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 Initiative Lead Date Initiated Status VRE colonization outbreak over July 2010. Continue with IPAC protocols and ICRT recommendations for E. Lipnicki Apr-10 Completed July 2010 surveillance and outbreak management policies ICRT invited for third party review July 20, 2010- waiting for final recommendations E. Lipnicki Jul-10 Completed Universal screening to be implemented to identify patients colonized with VRE on admission and thus reduce nosocomial spread IPAC Dec-10 In progress Page A10