Tsh scorecard corporate - 2010 11 q3 d

The Scarborough Hospital
Corporate Balanced Scorecard
Q3 2010/11

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

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

Current Status Legend: Risk Rating Legend
Red = Performance indicator has not met the target for the current reporting period, and has not improved over the prior reporting period L = Low reputational, financial or operational risk
Yellow = Performance is below the target, however it has improved over the previous reporting period M = Medium reputational, financial or operational risk
Green = Performance indicator has met or exceeded or is not statistically different than the performance target for the current reporting period H = High reputational, financial or operational risk

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

Page 1

Publicly Reported Patient Safety Indicators

Current Previous Current
Strategic Direction Indicator Value Value Target Status Risk Rating* Page
Our Patients: Emergency Department Wait Time for High Acuity Visits - General Campus 19:35 15:12 8:00 R H A1
Emergency Department Wait Time for High Acuity Visits - Birchmount Campus 22:51 12:12 8:00 R H A2
Emergency Department Wait Time for Low Acuity Visits - General Campus 5:31 4:48 4:00 R H A3
Emergency Department Wait Time for Low Acuity Visits - Birchmount Campus 4:57 4:30 4:00 R H A4
Percent of CTAS 1&2 meeting 8 hour target 66% 71% 90% R H A5
Percent of CTAS 3 meeting 6 hour target 66% 73% 90% R H A6
Percent of CTAS 4&5 meeting 4 hour target 79% 84% 90% R H A7
Rate of Hospital Acquired C. difficile Associated Diarrhea 0.32 0.22 0.28 R M A8
Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia 0.00 0.00 0.02 G n/a A9
Rate of Hospital Acquired Vancomycin Resistant Enterococcus (VRE) Bacteraemia 0.00 0.00 0.00 G n/a A10
Rate of Central Line Infection (CLI) 1.48 0.61 0.75 R A11
Rate of Ventilator Associated Pneumonia (VAP) 0.00 0.76 1.46 G n/a A12
Rate of Timely Administration of Prophylactic Antibiotics - Primary Hip & Knee 98.0% 97.6% 96.1% G n/a A13
Wait Time - General Surgery 82 67 182 G n/a A14
Wait Time - Cancer Surgery 65 54 84 G n/a A15
Wait Time - Cataract Surgery 123 223 182 G n/a A16
Wait Time - Total Hip Replacement 123 151 182 G n/a A17
Wait time - Total Knee Replacement 106 153 182 G n/a A18
Wait Time - CT 20 23 28 G n/a A19
Wait Time - MRI 99 116 28 Y M A20
* Risk rating only completed for indicators that are not meeting the target and have not improved over the prior reporting period

Status Legend: Risk Rating Legend
Red = Performance indicator has not met the target for the current reporting period, and has not improved over the prior reporting period L = Low reputational, financial or operational risk
Yellow = Performance is below the target, however it has improved over the previous reporting period M = Medium reputational, financial or operational risk
Green = Performance indicator has met or exceeded or is not statistically different than the performance target for the current reporting period H = High reputational, financial or operational risk

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

Page Addendum


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

Performance Measurement Summary
Definition

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

15:54, n=8051

15:48, n=8883

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

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

12:00

Target 10:00
MOHLTC Target - 8:00, lower value is desired.
8:00 CHART PLACEHOLDER
Risk Rating 6:00
High - There will be reputational impact of dissatisfied patients waiting in Emergency
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


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

Definition

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

17:02, n=6387

16:45, n=6561

16:31, n=6673
22:00

15:30, n=6325

14:06, n=6668
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
Laboratory Technologists G. Bajwa Sep-09 Ongoing
GEM E. Laine Jun-09 Ongoing
NP LTC S. Vellani Jun-09 Ongoing
Charge Nurse and Triage RN Education L. Vanden Kroonenberg Mar-10 Ongoing
ED PIP initiated N. Alli, T. Osgood May-10 In progress
Rounding for Outcomes M. Tang Jun-10 Ongoing
Schedule to Demand M. Tang Jan-11 Pending
Page A2


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

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

06:37, n=5220
9:00

06:07, n=5325

05:54, n=4487

05:42, n=4779
05:37, n=5477
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
6:00

5:00
Target
CHART PLACEHOLDER
3:00
Risk Rating
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
RPN Role D. Edman Jun-09 Ongoing
ED PIP initiated J. Phan, N. Velosos Sep-09 Ongoing
See and Treat Model of Care ED Staff Mar-10 In progress
Kaizen Events S. Gilbert Aug-10 In progress

Page A3


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

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

06:37, n=3905
9:00

06:07, n=3811

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

05:18, n=3980

05:00, n=3950

04:57, n=1188
Significance
7:00

04:30, n=3973
This indicator is associated with efficiency within the ED and within the hospital, as
6:00

5:00
Target
CHART PLACEHOLDER
3:00
Risk Rating
1:00
Analysis
There are challenges related to flow of patient treatment between major and minor 0:00
cases.

Birchmount Target

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

Page A4


Indicator Percent of CTAS 1&2 meeting 8 hour target

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

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

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

71%, n=2787
70%, n=2332
69%, n=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%
Analysis 10%
0%
procedures. A Diagnostic Imaging Kaizen event is taking place to improve
Diagnostic Imaging callbacks wait times.

General Birchmount TSH Target

Action Plan
Page A5


Indicator Percent of CTAS 3 meeting 6 hour target

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

73%, n=4877

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

70%, n=7756
90%

67%, n=3203

67%, n=1486

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

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

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

60%, n=3399
80%

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

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

51%, n=2604

60%

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

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


Action Plan
Page A6


Indicator Percent of CTAS 4&5 meeting 4 hour target

Definition

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

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

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

76%, n=4280

76%, n=3093

78%, n=988
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

60%

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


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

Page A7


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

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

0.48, n=4
0.47, n=7
0.47, n=7

0.47, n=7
0.47, n=3
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
0.24, 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,
0.16, n=1
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 10

Apr 10

May 10

Aug 10

Sep 10

Feb 11

Apr 11

May 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
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


Indicator Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia
Time Frame Q4 2010/11

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.


Action Plan
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


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

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
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.




Action Plan
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


Indicator Rate of Central Line Infection (CLI)

Definition

6.32, n=6
Overall rate of hospital acquired Central Line Infection. Rate is based on total 7.00
number of CLI incidents diagnosed after two days of Critical Care admission per
1000 patient days.

4.98, n=5
6.00

4.58, n=6
Significance
5.00

3.90, n=6
To track hospital acquired CLI rates in order to identify and implement necessary
prevention plans to reduce the risk of infection from spreading.
4.00

2.54, n=1
2.36, n=1

2.31, n=3
2.21, n=2

2.06, n=3
Target
3.00

1.88, n=1
1.87, n=1
Ontario Average - 0.75, lower value is desired.

1.48, n=3
CHART PLACEHOLDER

1.14, n=1
Risk Rating 2.00

0.75, n=1

0.69, n=1

0.61, n=1
n/a

0.00, n=0

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

0.00, n=0

0.00, n=0

0.00, n=0

0.00, n=0
1.00
Analysis
There has been a marked improvement to the number of CLI cases at TSH in
January 2011. CLI strategies to standardize processes across the campuses is 0.00
showing improvements in the rates. Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11


Action Plan
H. Clasky, D. Rose, S. Cesta, Jan-10 Ongoing
Interdisciplinary team meetings to standardize protocols at the Birchmount Campus including physician and
nursing education R. Lovinsky
H. Clasky, D. Rose, S. Cesta, Apr-10 Completed
Chlohexidine dressings to help prevent CLIs R. Lovinsky
H. Clasky, D. Rose, S. Cesta, Apr-10 Ongoing
Ongoing monitoring of insertion and maintenance Bundle R. Lovinsky

Page A11


Indicator Rate of Ventilator Associated Pneumonia (VAP)

Definition

4.56, n=2
Overall Rate of hospital acquired Ventilator Associated Pneumonia. Rate is based 5.0
on total number of VAP incidents diagnosed after two days of Critical Care
admission per 1000 patient days. 4.5

4.0
Significance
To track hospital acquired VAP rates in order to identify and implement necessary 3.5

2.47, n=2
prevention plans to reduce the risk of development of pneumonia in the ICU patient
population. 3.0

1.76, n=1
2.5

1.63, n=2
1.58, n=2
Target

1.40, n=1
1.31, n=1

1.14, n=1
0.97, n=1
CHART PLACEHOLDER

0.90, n=1
0.78, n=1

0.76, n=1
1.5
Risk Rating
n/a 1.0

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 0.5
There were no VAP cases identified at TSH in January 2011.
0.0
Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11


Action Plan
Interdisciplinary meeting with Birchmount Critical Care team to ensure compliance with safer healthcare bundle. Dr. Clasky, C. Shelton, S. Jan-11 In progress
Development of unit based scorecard to track progress. Ensure standardization between campuses. Cesta, R. Lovinsky
Continue monitoring compliance bundles (maintenance and insertion) J.MacIsasc Jan-11 In progress

Page A12


Indicator Rate of Timely Administration of Prophylactic Antibiotics - Primary Hip & Knee
Source Medical Systems Management (OR System)

Definition

95.7%, n=178

95.8%, n=249

99.2%, n=243
98.7%, n=74
99.1%, n=317

98.7%, n=231

99.0%, n=291

99.1%, n=216

98.3%, n=286

99.4%, n=155
98.2%, n=56
99.1%, n=211

97.3%, n=215
98.5%, n=64
97.6%, n=279

97.2%, n=205

98.0%, n=290
100.0%, n=60

100.0%, n=85
120%

95.9%, n=71

95.9%, n=70
Surgical site infections occur when harmful germs enter a patient’s body through the
surgical site (any cut the surgeon makes in the skin to perform the operation). Ways
to prevent surgical site infections is by giving patients antibiotics 0 to 60 minutes or
0 to 120 minutes (vancomycin antibiotic) before they undergo surgery. 100%
Significance
Conducting post-surgical infection surveillance and measuring the application of
prophylactic antibiotics can be useful to enhance safety and quality of care, and to 80%
prevent complications thereby decreasing morbidity and mortality rates.

Target 60%
Ontario Average - 96.1%, higher value is desired.
CHART PLACEHOLDER
40%
Risk Rating
n/a

20%
Analysis
All surgeon's offices have pre-printed orders. Work continues on ensuring a good
process for improvement on this indicator. The drop at Birchmount Campus was
due to one case where the patient received the antibiotic outside the recommended 0%
time. This was because pre-op orders did not reference that Clindamychi must be Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11
given 60 minutes pre-op. This has now been rectified.

General Campus Birchmount Campus TSH Ontario Avg.Target

Action Plan
Ensure compliance through audits PCMs Apr-09 In progress
Implement standard order sets to improve compliance Nurse Educators Sep-09 Completed

Page A13


Indicator Wait Time - General Surgery
Time Frame Q4 2010 (Jan-Feb)
Source MOHLTC Wait Times Website / CCO IPort

Definition
Wait time is defined as the 90th percentile number of days between the date of 200
decision to treat and the time the surgical procedure is performed.
180

160
Significance
A measure of access and efficiency for patients requiring these procedures. 140

88, n=524
87, n=499
120

84, n=279

83, n=419

82, n=356
75, n=397

75, n=415
68, n=279

68, n=475
67, n=314

67, n=457
100

61, n=387
Target
80
MOHLTC Target - 182, lower value is desired.
CHART PLACEHOLDER
60
Risk Rating
n/a 40

20
Analysis
General Surgery is performing well against Ontario average and provincial target. -
Patients are seen in a timely manner.

TSH Ontario Target

Action Plan
Hire of two new General Surgeons TSH Senior team Dec-09 Completed
Continue to monitor the performance of surgeon, wait time and OR blocks utilization N. Rahim Dec-10 Ongoing
Allocate OR time to services with wait time cases N. Rahim Dec-10 Ongoing

Page A14


Indicator Wait Time - Cancer Surgery

Definition
90

74, n=223
Wait time is defined as the 90th percentile number of days between the date of

65, n=267
80

60, n=217

59, n=192

57, n=191
70

54, n=173
53, n=234

50, n=169
Significance

49, n=221
46, n=159
A measure of access and efficiency for patients requiring these procedures. 60

43, n=100
50

40
Target
30 CHART PLACEHOLDER
Risk Rating 20
n/a
10
Analysis
Cancer Surgery is performing well against Ontario average and provincial target. -
Patients are seen in a timely manner.

TSH Ontario Target

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

Page A15


Indicator Wait Time - Cataract Surgery

Definition

212, n=1368

223, n=1331
197, n=1438

165, n=1134
157, n=1409

155, n=1434
150, n=1613

149, n=1325
200

145, n=1418

145, n=1453
138, n=1423
Significance

123, n=1242
A measure of access and efficiency for patients requiring these procedures.
150

Target
100
CHART PLACEHOLDER
Risk Rating
n/a
50

Analysis
The wait time for cataract surgery has decreased between January to February -
2011 below the provincial target. Previous wait times was due to the lack of funding
from CE LHIN for 2010/11. Funded volumes have decreased for TSH by 315 cases
compared to 2009/10. In Q4 the CE LHIN allocated additional 400 cataracts to
assist TSH to bring down the 90th percentile for cataracts. The additional cataract
volumes have already impacted January's wait time. Q4 wait times will also be lower
than Q3 due to data clean-up efforts undertaken. TSH Ontario Target

Action Plan
Continue to monitor the performance of surgeons, wait time and OR blocks utilization N. Rahim Dec-10 Ongoing
Allocate OR time to the Ophthalmology surgeons with wait times exceeding the WTIS target of 182 days N. Rahim Oct-10 In progress
Ensure data quality check and re-education of Ophthalmology office staff to understand how to use of Decision N. Rahim Jan-11 In progress
Affecting Readiness to Treat (DARTs) Option on patients Wait Time records

Page A16


Indicator Wait Time - Total Hip Replacement

Definition

171, n=52
200

151, n=63
146, n=77
145, n=61
Significance

131, n=64
130, n=50

124, n=57

123, n=43

117, n=43

116, n=74
114, n=62
108, n=87
150

Target 100
CHART PLACEHOLDER
Risk Rating 50
n/a

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

TSH Ontario Target

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

Page A17


Indicator Wait Time - Total Knee Replacement

Definition

192, n=202

159, n=181

153, n=222
200

145, n=242
Significance

130, n=159
124, n=221

124, n=236

124, n=222

117, n=223

114, n=241
113, n=202

106, n=144
150

Target
MOHLTC Target - 182, lower value is desired. 100
CHART PLACEHOLDER
Risk Rating
n/a 50

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

TSH Ontario Target

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

Page A18


Indicator Wait Time - CT

Definition

41, n=4757
Wait time is defined as the 90th percentile number of days wait for CT diagnostic 50

39, n=5176
38, n=5105

38, n=5077
scan.

36, n=5387
45

34, n=5091

32, n=5030
40

29, n=5169
Significance
35
Track the wait time indicators to ensure that we are meeting our MOHLTC

23, n=5177

23, n=5605
21, n=5510
commitments and meeting the needs of our patients.
30

20, n=3968
25
Target 20
15
CHART PLACEHOLDER
Risk Rating
10
n/a
5
Analysis
Reduction noted based on changes to scheduling patterns and improvement in data -
capture as a result of retraining of staff. There are longer waits for priority 3, as
many requests involve the use of contrast media and these appointments are
limited.

TSH Ontario Target

Action Plan
Wait time data entry training for booking clerks V. Winters Nov-09 Completed
WTIS data error resolution done on a monthly basis - indicates data entry errors - follow up with staff Charge clerks Nov-09 In progress
Application for second CT at General Campus in Satellite location; will decrease all Wait Times T. Jackson Sep-10 Pending
Review existing contrast media delivery policy and explore options for extending contrast appointments T. Jackson Sep-10 Pending

Page A19


Indicator Wait Time - MRI

Definition

118, n=2240

133, n=2121

116, n=2132
109, n=2028
140

107, n=2085
Wait time is defined as the 90th percentile number of days wait for MRI diagnostic

103, n=1895
101, n=1718
scan.

99, n=1954
99, n=1844
120

79, n=1744
Significance 100
Track the wait time indicators to ensure that we are meeting our MOHLTC

64, n=1635
61, n=1844
commitments and meeting the needs of our patients.
80

Target 60
CHART PLACEHOLDER
40
Risk Rating
Medium - delays can affect patient care. P4 are the lowest priority. Long waits can
20
negatively impact reputation.
Analysis
-
MOHLTC target for priority 4 cases is 28 days and the CELHIN has a target of 76.5
days. Currently exceeding both. Demand for services continues to outstrip
available resources. Current MRI Process Improvement Project (PIP) process is
reviewing scheduling process for efficiencies. TSH receieved funding from CELHIN
in Q4 for 360 additional MRI hours in hopes of decreasing wait times.

TSH Ontario Target

Action Plan
Wait time data entry training for booking clerks V. Winters Nov-09 Completed
WTIS data error resolution done on a monthly basis - indicates data entry errors - follow up with staff Charge clerks Nov-09 In progress
MRI PIP- LEAN process for identifying improvements in MRI throughput S. Porter Jun-10 In progress
Second MRI application sent to CELHIN, LHIN approval moved to MOHLTC T. Jackson Jul-10 In progress
Operating hours extended to 24hrs during weekdays for Q4 2010/11 S. Porter Jan-11 In progress

Page A20


Indicator Patient satisfaction - Overall Impression (Emergency Department and In-patients)
Source NRC Picker

Definition
Response to Overall Impression questions in NRC Picker survey administered to a 100
sample of discharged Emergency Department patients and In-patients:
- Emergency Department (ED): Would you recommend TSH for Emergency

67.2 n=271
Department services?

62.6 n=342
80

61.9 n=318
- Inpatients: Would you recommend TSH for an In-patient stay?

60.9 n=322
60.4 n=359

59.4 n=330
59.3 n=327
Significance

49.7 n=193

49.1 n=116
48.3 n=143
46.8 n=154
This indicator is a measure of patient's overall impression of the quality of care

44.3 n=212
received. 60

41.5 n=135
36.4 n=151
Target
TSH target is 50 for ED and 73 for IP, higher value is desired. The target is based
on GTA average. 40 CHART PLACEHOLDER

Risk Rating
High- Reputational, financial or operational risk.

20
Analysis
TSH Emergency Department satisfaction scores is below the target. TSH Inpatient
satisfaction scores continue to be below other Greater Toronto Area hospitals. TSH
has made positive changes such as Code of Conduct, and faster response time to
0
patient complaint by Patient Relations department.
Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11
ED Score IP Score Target - GTA ED Avg Target - GTA IP Avg

Action Plan
QCIPA Reviews ED Leadership Team Sep-10 Ongoing
• QCIPA case reviews take place whenever an incident, near miss or adverse event occurs
• Recommendations are shared with staff
Team Charter, the ED Team Charter defines the purpose of the team, how we all work together and what the Nursing Leadership Team and Sep-10 Ongoing
expected outcomes will be: ED staff
• Utilized to lay the foundation of expected team behaviours
• Utilized to guide staff in their performance and interactions with patients
Hiring the right people for the team. The ED will recruit and retain professionals with the right level of knowledge, D. Edman and T. Reardon Sep-10 Ongoing
technical expertise and interpersonal skill.
• Select new staff who will make a positive difference to our patients
• Select staff who support our mission, vision and values
Page 2

Staff Education, all staff are giving an opportunity to enhance or increase their knowledge and skill: S. Gilbert and L. Vanden Sep-10 Ongoing
• Charge Nurse workshops Kroonenberg
• Triage Nurse workshops
• Monthly inservicing on selected topics
• Customer service education
Patient friendly waiting room D. Edman and T. Reardon Sep-10 Completed for General Campus
General Campus:
• ED Activity board in place to inform patients in the waiting room about potential wait time
• Wayfinding steps to triage, registration and wait room in place to ensure patients queue appropriately
Birchmount Campus
• Re-design waiting room, triage and registration in process
• ED activity board in process
Fast track RAZ patients D. Edman and N. Alli Sep-10 Completed for Birchmount
General Campus: Campus
• Elite RAZ staff
• Number system to ensure patients are aware of who is next in line
• Pull to RAZ waiting room
Birchmount Campus:
• Elite RAZ staff
• Pull to RAZ waiting room

Page 3


Indicator Percentage of publicly reported patient safety indicators meeting the provincial target (see addendum)
Source Meditech, NACRS, IPAC, MOHLTC Wait Times Public Website

Definition
120%
Percentage of 19 publicly reported patient safety indicators that meet the provincial
targets.
Significance
100%
Provides information on patient safety issues where the goal is to enhance patient
safety in the hospital by reducing the risk factors. Monitoring these indicators in the
hospital is a priority and is key to keeping patients safe.

63%, n=12

63%, n=12

63%, n=12
80%

58%, n=11
Target

53%, n=10
TSH Target - 100%, higher value is desired.
Risk Rating
n/a 60%
Analysis
CHART PLACEHOLDER
• There continues to be improvement in our high and low acuity scores at both the
General and Birchmount campus compared to a year ago. 40%
• There have been an increase in cases of C. Diff at the General campus since Dec-10.
Rates have begun to decline with increased monitoring and vigilence of infection control
practices in the inpatient areas. The Birchmount campus remains below the Ontario
20%
average.
• There has been a decrease in the number of CLI cases at the Birchmount campus.
Overall, TSH remains below the Ontario average. Standardization of CLI strategies
across the campuses will assist in decreasing CLI cases across TSH. 0%
• There has been some decrease in VAP cases identified at the General campus and
Birchmount campus in the last quarter. Both campuses are now below the Ontario Q3 2009/10 Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11
average.
• SSI - Antibiotics Timing - Hip/Knee: Work continues on ensuring a good process for % patient safety indicators meeting provincial targets Target
improvement on this indicator.
• TSH patients continue to receive timely access to care. TSH wait time for general surgery, hip/knee, CT is below the provincial average.
• The wait time for MRI is above the Ontario average, however, the wait time has increased to 116 in Q3 2010/11.
• The wait time for cataract surgery has increased in Q3 2010/11 above the provincial target. There is a lack of funding from CE LHIN for 2010/11. Funded volumes have decreased for TSH by 315
cases compared to 2009/10. Wait time for cataracts will continue to increase unless additional funding is received.

Action Plan
Implement standard order sets to improve compliance Nurse Educators Sep-09 Completed
Early cluster identification and interventions including unit terminal cleaning, use of vernacare system, re- IPAC Sep-09 Ongoing
enforcement/education on hand hygiene, cleaning of equipments between patients and prudent use of antibiotics

Continue to monitor CLI and VAP bundle compliance in Intensive Care Unit Dr. I. Daves, B. Westcott, IPAC Sep-09 Ongoing

An additional 300 hours of wait time funding accepted from CE LHIN reallocation. Implementation of expanded T. Jackson Sep-09 - Mar-10 Completed
hours of operation to commence Sep-09
Interdisciplinary meeting with Birchmount critical care team to ensure compliance with safer healthcare bundle. Dr. Clasky, C. Shelton, S. Cesta, Jan-10 In progress
Development of unit based scorecard to track progress. Ensure standardization between campuses R. Lovinsky

Page 4

Continue with notification to pharmacy regarding patient’s with diarrhea, early use additional precautions on IPAC Jan-10 Ongoing
symptomatic patients until C. Diff is ruled out and standardization of cleaning protocols and products for both
campuses
Increased vigilence to IPAC guidelines around C. Diff management for both campuses E. Lipnicki Feb-10 Ongoing
Re institution of the Antibiotic Stewardship Committee to ensure prudent use of antibiotics. Development of a IPAC Feb-10 In progress
corporate policy for cleaning and disinfecting shared equipments and separation of clean and soiled utility room.
Plan for increase vernacare waste macerators
Collaborate with IPAC, Critical Care, Diagnostic Imaging, IV resource and Physician team on type of line to be B. Westcott, Dr. H. Clasky, Dr. R. Feb-10 In progress
inserted, compliance with insertion and maintenance bundles. Focus on hand hygiene improvement, reinforce Lovinsky, IPAC
importance of aseptic line access, timely removal of central lines, educate Physicians on line removal, empower
nurses to prompt line discontinuation, improve line documentation
Continue to ensure compliance with SSI - Antibiotics Timing (Hip/Knee). Overall compliance rate is currently N. Rahim Feb-10 Ongoing
99%
With the addition of 3 General surgeons, access to care should further improve. Continue to monitor wait times N. Rahim Feb-10 Ongoing
and ensure TSH is meeting funded volumes
Continue to deliver cataract surgery to funded volumes only. Funding for an additional 123 cases has been N. Rahim Feb-10 Ongoing
received. This volume has already been delivered. Additional finding of 375 cases requested from the CE LHIN

Investigate feasibility of extending contrast cases to off-hours: Not supported at this time T. Jackson Feb-10 Completed
Pursue 2nd CT scanner to increase capacity: Not approved to commence procurement. Linked to achievement of T. Jackson Feb-10 Pending
agreed upon nuclear cardiology referral volumes, which have not yet been met
ED Process Improvement Project (PIP) has re-designed the Rapid Assessment Zone (RAZ) for a team approach L. Crawford, A. MacKinnon, J. Mar-10 Completed
to see and treat Phan
Clinical Decision Unit (CDU) L. Crawford, Dr. T. Chan Mar-10 Completed
Virtual CDU L. Crawford, Dr. T. Chan Mar-10 Ongoing
VRE colonization outbreak over Jul-10. Continue with IPAC protocols and ICRT recommendations for E. Lipnicki Apr-10 Completed
surveillance and outbreak management policies
Continue to work with the Antibiotic Stewardship Committee to ensure prudent use of antibiotics to lower and IPAC, Dr. R. Lovinsky May-10 In progress
maintain rates below the provincial average
CLI Rates beginning to drop with subsequent months for the General campus. Continue to monitor progress and B. Westcott, Dr. H. Clasky, Dr. R. May-10 In progress
collaborative work as outlined below Lovinsky, IPAC
ED PIP L. Crawford, A. MacKinnon, Dr. T. May-10 – General In progress
Chan Dec-10 – Birchmount
Staffing demand for nursing and physicians. Master schedule for nursing staff to be implemented June 21, 2010 L. Crawford, A. MacKinnon, D. Jun-10 Ready for implementation
Edman, Dr. T. Chan
Review of "vernacare" system for both campuses emphasizing safe disposal of waste. 4 new vernacare units E. Lipnicki Jun-10 In progress
approved for Birchmount campus in 2010 capital plan
MRI PIP - LEAN process for identifying improvements in MRI throughput S. Porter Jun-10 In progress
Continue with MRSA surveillance protocols E. Lipnicki Jul-10 Ongoing
ICRT invited for third party review July 20, 2010 - waiting for final recommendations E. Lipnicki Jul-10 Completed
Second MRI application sent to CE LHIN, LHIN approval moved to MOHLTC T. Jackson Jul-10 In progress
Pay for Performance (P4R) funding received for year III: Electronic Bed Board; Clinical Facilitator; Laboratory L. Crawford, A. MacKinnon, Dr. T. Fall 2010 In progress
Technologists; See and Treat; Staff to Demand; Rapid Admissions Unit (RAU); LEAN; ED PIP extension Chan

ED PIP commenced Apr-10 at the Birchmount campus. Value Stream Mapping (VSM) completed. Entering L. Crawford,A. MacKinnon, N. Alli Sep-10 In progress
solution design stage with launch on May 26, 2010
RAU L. Crawford, A. MacKinnon, N. To be integrated into base – Sep- Ongoing
Veloso 10
ED wait times may not be met due to influenza surge during Q3. Cataract surgery wait times down to below E. Lipnicki Feb-11 Ongoing
target after significant clean up of wait time data in surgeons' offices completed by TSH staff. Continue with
additional cleaning of C-diff affected units and auditing of infection control practices on these units. Plans in the
works for additional MRI scanner installation at Birchmount summer 2011. This will help reduce MRI wait time

Page 5


Indicator Number of incident reports completed (medication and non-medication)
Time Frame Q4 2010/11 (projected based on Jan-Feb 2011)
Source S.A.F.E. (rLSolutions)

Definition
800

743
Incident reports are one mechanism to capture the occurence of an actual or

730
705
potential adverse event in an organization (others include chart reviews, patient
complaints, etc.). An online webbased system (S.A.F.E.) provided by RL Solutions 700

626
is used at TSH to report patient, visitor and staff actual and potential adverse events

576
as well as track follow-up actions for these events.
600

521
Significance

467
To track trends in adverse events in order to identify and implement necessary 500
improvement plans.

403
Target
400
TSH Target - 490, higher value is desired. The target for this indicator has been
established as a 5% increase from the corresponding quarter in the previous fiscal
year. 300 CHART PLACEHOLDER
Risk Rating
n/a 200

Analysis 100
TSH is currently meeting target in this quarter. The experience in Canadian and
U.S. hospitals is that adverse events are underreported and it can be assumed that 0
TSH is no different. Therefore, the objective is to increase incident reporting, as
Q1 Q2 Q3 Q4 (projected based on
least in the short term.
Jan-Feb 2011)

2009/10 2010/11 Target

Action Plan
Monthly reports provided to each PSG director Performance & Decision Support Apr-10 Ongoing
Quality of Care Committee reviews critical incident reports at each meeting and tracks status of C. Hendriks Oct-10 Ongoing
recommendations
Risk Management making regular report on incident trends and critical incidents quarterly to MAC C. Hendriks Oct-10 Ongoing

Page 6


Indicator Hospital Standardized Mortality Ratio (HSMR)
Time Frame 2010/11 (Apr-Dec)
Source The Canadian Institute for Health Information (CIHI)

Definition
The ratio of actual in-hospital deaths to the expected number of in-hospital deaths 160
for conditions that account for 80% of in-patient mortality. Where a HSMR score of

137

132

131
100 represents the actual number of deaths equal to the expected number of 140

129

127
126

124
deaths. A number above 100 indicates a higher than expected number of deaths

122

122
120
and a number below 100 indicates a lower than expected number of deaths.

114

114

112

112
120

109

106
105

97
100

84
88
Significance

80
This is a global indicator for patient safety and the quality of care provided within a

75

74
80

73
facility.

60 CHART PLACEHOLDER
Target
TSH Target - 100, lower value is desired.
40

Risk Rating
n/a 20

Analysis 0
The 2009/10 year-end TSH HSMR showed dramatic improvement with the publicly 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11
released value of 84. We now rank within the top 10 in the GTA and 4th amongst (Apr-Dec)
peer community hospitals.

Action Plan
The following initiatives are underway: Dr. S. Jackson Feb-10 Ongoing
• Mortality Chart Review (current)
• Quality of Care Committee (Feb-10)
• Face Sheet implemented Nov-10
• Hospitalists 4 in place on 2 wards as of Feb-11

Page 7


Indicator Rate of hand hygiene compliance

Definition

99%, n=655
98%, n=1534

98%, n=2430

96%, n=4248
98%, n=644
120%

97%, n=879

94%, n=2334

94%, n=1818
93%, n=1464

96%, n=491
92%, n=4049
The single most common way of transferring health care-associated infections (HAIs)

90%, n=1715

90%, n=384
90%, n=820

90%, n=463

89%, n=875
in health care settings is on the hands of health care providers. Health care providers

85%, n=803
move from patient to patient and room to room while providing care and working in the

81%, n=340
patient environment. This movement provides many opportunities for the transmission 100%
of organisms on hands that can cause infections.

80%
Significance
Proper hand hygiene protects patients and providers and will reduce the spread of
infections and the associated treatment costs, reduce hospital lengths of stay and
readmissions, reduce wait times, and prevent deaths. 60%

Target. CHART PLACEHOLDER
40%
Ontario Target - 90% Before and 90% After, higher value is desired.

Risk Rating
20%
n/a

Analysis 0%
Due to the lack of modified workers and the VRE issue, there were not enough audits
Before After Before After Before After
done to report for Q3 at the General Campus. The data for the Birchmount Campus
exceeds the target for After care.
2008/09 2009/10 2010/11

General Campus Birchmount Campus TSH Target

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

Page 8


Indicator Employee Satisfaction survey results (Commitment composite score)
Strategic Direction Our People
Time Frame 2010/11
Source NRC Picker

Definition

50.9%, n=1590
The Employee Opinion Survey measures employee satisfaction on various scales. 60%
Employee Commitment composite score is shown on the scorecard. Scores are out
of 100. Commitment score is composed of average scores from 5 questions: i)
Organization is great to work for ii) Proud to say part of organization iii) My
50%

37.5%, n=1606
values/organization's values are similar iv) Organization inspires best in you v) Glad
chose organization over others.

40%

Significance
To track trends in employee satisfaction in order to identify and implement
necessary improvement plans. 30%

CHART PLACEHOLDER
Target
Ontario Average - 59% for 2010/11 and 55% for 2008/09, higher value is desired. 20%

Risk Rating
n/a
10%

Analysis
All Hospital Average commitment scores for employees is 59.4% and Physician All
Hospital Average for commitment is 43.1%. EOS increased by 13.1% and POS by 0%
13.9%. Although we did not meet the target of 55% ,our data clearly indicates a 2008/09 2010/11
statistically significant positive trend in commitment. Addressing prioritized areas of
improvement both at the Corporate and unit level will continue to positively impact Commitment Score Target
commitment scores going forward.

Action Plan
Violence in the Workplace- Organized polices; Code White, harassment, discrimination, code of conduct and S. Rai-Lewis Mar-10 Completed
violence in the workplace under one heading – Respect in The Workplace. Rollout of training on Bill 168 to be
completed in June. Ongoing training through learning institiute
Employee Opinion Survey to be administered every 2 years, next full survey will be September 2010 S. Rai-Lewis Sep-10 Completed
Introduce Pulse Survey to measure engagement (quarterly snapshot) S. Rai-Lewis Fall 2011 Scheduled for Fall 2011

Page 9


Indicator Physician Satisfaction survey results (Commitment composite score)
Time Frame 2010/11
Source NRC Picker

Definition
The Physician Opinion Survey measures physician satisfaction on various scales. 60%
The physician commitment composite score is shown on the scorecard. Scores are

42.7%, n=151
out of 100. Commitment score is composed of average scores from 5 questions: i)
Organization is great to work for ii) Proud to say part of organization iii) My 50%
values/organization's values are similar iv) Organization inspires best in you v) Glad
chose organization over others.

28.8%, n=141
40%

Significance
To track trends in physician satisfaction in order to identify and implement 30%
necessary improvement plans.
CHART PLACEHOLDER
Target 20%
Ontario Average - 43% for 2010/11 and 45% for 2008/09, higher value is desired.

Risk Rating 10%
n/a

Analysis 0%
The 2010 survey shows dramatic improvement as compared to 2008. The 2010
2008/09 2010/11
commitment score of 42.7 is now comparable to the hospital average.
Commitment Score Target

Action Plan
Performance review taking into account values including code of conduct Dr. S. Jackson Apr-10 Ongoing
Development of robust communication with family physicians Dr. S. Jackson Apr-10 Ongoing
The development of the The Clinical Services Plan Dr. S. Jackson Apr-10 Ongoing
The development of Physician leadership award Dr. S. Jackson Apr-10 Ongoing

Page 10


Indicator Percentage of defined Model of Care positions transitioned
Time Frame 2010/11
Source Internal Tracking

Definition

100%, n=21
120%
Percentage of clinical resource staff (i.e. nurse educators and nurse clinician) who
have transitioned and are functioning in the new Clinical Resource Leader role.

100%

Significance
Model of Care positions supports excellent care and full scope of practice and
enhances partnerships between practice and operations. 80%

Target 60%
100%
CHART PLACEHOLDER
Risk Rating 40%
n/a

Analysis 20%
All positions have been transitioned and all are functioning in the role.

0%
2010/11

% positions transitioned Target

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

Page 11


Indicator Percentage of Medical Directors with completed performance evaluations
Source Internal Tracking

Definition
120%
Percentage of Medical Directors with completed annual performance evaluations.
Percentage based on total number of Medical Directors in the hospital.

100%

80%, n=8
Significance
Employee evaluation is important for development of staff and managers to be
aware of employee development needs. 80%

Target 60%
Internal Target - 100%, higher value is desired.
CHART PLACEHOLDER
Risk Rating 40%
n/a

Analysis 20%
Performance evaluations are on track to be completed by the end of the fiscal year.

0%
Q3 2010/11

% Medical Directors with completed evaluation Target

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

Page 12


Indicator HIT indicator #17, Percentage of equipment cost to total expense
Strategic Direction Our Programs, Plans and Partners
Time Frame 2010/11 (Apr-Sept)
Source Healthcare Indicator Tool (HIT)

Definition
Total equipment cost (including depreciation rental/lease and maintentance cost) as 7.0%

6.2%

6.2%
a percent of total hospital expense.

5.6%
6.0%

5.4%
5.2%

5.2%
Significance
To track our investment in equipment and technology in comparison to our industry. 5.0%

4.0%

Target
LHIN Average - 5.9%, target value is desired. 3.0%
CHART PLACEHOLDER
Risk Rating 2.0%
Medium - Impact would be operational (i.e. quality).

1.0%
Analysis
Lack of investment in equipment and technology may impact quality of care and
performance. Equipment depreciation has declined due to delay in acquisition of 0.0%
new equipment (i.e. CTs).
2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 (Apr-
Sept)

% of equipment cost to total expense Target

Action Plan
Expedite acquisition of major pieces of equipment included in 2010/11 Capital Plan R. Anstey Feb-11 In progress

Page 13


Indicator Percentage of PMO project milestones met
Strategic Direction Our Programs, Plans, and Partners
Source Eclipse project management application

Definition
A number of initiatives for the department have been agreed upon at the outset of 120%

96%, n=22
94%, n=15
the fiscal year. Each initiative has milestones that must be achieved. This measure
represents all milestones achieved for all initiatives as a percentage.
100%
Significance
A measure of department performance, efficiency and planning.
80%

47%, n=20
Target 60%
CHART PLACEHOLDER

Risk Rating 40%
Medium- Reputational, financial or operational risk.

20%
Analysis
In Q3 2010/11, fourty-three milestones were being tracked by the PMO. In this
quarter, 20 of 43 milestones have been met.
0%
Q1 2010/11 Q2 2010/11 Q3 2010/11

% milestones achieved Target

Action Plan
Monthly status reports required from each project manager to report on project status, met and missed J. Cox Sep-10 Ongoing
milestone, project risks
PMO Advisory Committee Coach assigned to each project to provide advice on Status Report content C. Flemming Sep-10 Ongoing
Inventory of task timelines being development to guide future project plans (e.g. RFP development and positng, J. Cox Oct-10 Ongoing
contract negotiation, hardware procurement)
PMO Lead reviewing all project milestones to ensure they meet the milestone definition and that there are J. Cox Oct-10 Ongoing
sufficient milestones to track the project. Feedback provided to project managers
Largest proportion of missed milestones were presentation of Business Cases. These presentations are C. Flemming Feb-11 Ongoing
scheduled for March 7

Page 14


Indicator Percentage of Programs and Departments with performance indicator scorecards and action plans that are posted and updated quarterly on the Intranet
Strategic Direction Our Performance
Source Performance & Decision Support

Definition
A Corporate Scorecard (1) has been developed, along with scorecards for each 120%
VP/ED portfolio (7), PSG and clinical support department (12). This measure
reflects whether the scorecards (including action plans) were published and posted

85%, n=17
on the SharePoint. 100%

75%, n=15

75%, n=15
Significance
Routine uploading of scorecards will facilitate regular review of the indicators and
transparency to the staff and other departments. 80%

Target 60%
CHART PLACEHOLDER
Risk Rating 40%
n/a

Analysis 20%
A schedule has been developed for VP/ED scorecard reporting at the weekly Senior
Management Team (SMT) meeting. The Performance & Decision Support PDS
consultant is responsible for building and maintaining scorecards for their respective 0%
PSGs on a quarterly basis. There are a total of 20 Scorecards (1 Corporate, 7
Q1 2010/11 Q2 2010/11 Q3 2010/11
VP/ED, and 12 PSG/Depart.).

% of posted scorecards Target

Action Plan
VP/ED Scorecard SMT presentation schedule established C. Flemming Aug-10 Completed
VP/ED Scorecards to be sent to PDS upon completion for publication on the PDS SharePoint site C. Flemming Aug-10 Pending
Discuss QIP and VP/ED Scorecards at March SMT meeting C. Flemming Feb-11 Pending

Page 15


Indicator Total margin
Time Frame 2010/11 (Apr-Jan)
Source Finance

Definition
Total margin is the percentage by which total revenues exceed or fall short of total 1.00%
expenses. A positive percent indicates an operating surplus position where a
negative percent reflects an operating deficit position.

0.50%
Significance
To ensure the Hospital is operating in a balanced or surplus position.

0.00%
2006/07 2007/08 2008/09 2009/10 2010/11 (Apr-Jan)

Target
TSH Target - 0%, target value is desired. -0.50%
CHART PLACEHOLDER
Risk Rating
n/a -1.00%

Analysis
April to January result of 0.30% reflects a surplus of $690K for the first 9 months of -1.50%
2010/11.

-2.00%

Total Margin Target

Action Plan
Quarterly review by Senior Management Team to ensure a total margin of 0% or better is maintained R. Anstey Jul-10 In progress

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Indicator Percentage of accountability agreement indicators achieved
Source Finance

Definition
120%

100%, n=8
Overall percent achievement of 8 accountability agreement indicators:
(Total Margin, Current Ratio, % FT Nurses, Weighted Cases, MH Patient Days,
Rehab Patient Days, ER Visits, Amb Visits).

88%, n=7

88%, n=7

88%, n=7
100%

75%, n=6

75%, n=6
Significance
Track volumes for the indicators in the Hospital's Accountability Agreement to
ensure that we are meeting our MOHLTC commitments. 80%

60%
Target
TSH Target - 80%, higher value is desired.
CHART PLACEHOLDER
40%
Risk Rating
n/a

20%
Analysis
In Q3 the rehab Patient days target has not been achieved as we are experiencing a
decline in this service as patients are being discharged earlier and rehab is taking
place on an outpatient basis or at a designated rehab facility. There are possible 0%
financial penalties associated with not meeting accountability agreement 2007/08 2008/09 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11
commitments.

% accountability agreement indicators achieved Target

Action Plan
Continue to monitor financial results R. Anstey Jul-10 In progress
Investigate Rehab patient day volumes R. Anstey, E. Lipnicki Aug-10 In progress

Page 17

Tsh scorecard corporate - 2010 11 q3 d

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