Board Monitor – Quarterly Report

Board Monitor – Quarterly Report Quality and Performance Indicators December 2007

Table of Contents HHS Strategy Map 3 Introduction 4 Goal #1 - We meet or exceed our communities’ expectations 5 Goal #2 - We are internationally recognized for the excellence or our patient-centered care, research and education 12 Goal #3 - We have a healthy work environment 18 Goal #4 – We have a sound financial base to sustain our mission and achieve our vision 22 Goal #5 –We create a sustainable and aligned system through action and leadership 26

Access to Care Quality Initiatives Operational Performance Healthy People and Environments System Thinking & Leadership Human Capital Learning & Innovation Perspective Organization Capital Culture Leadership Corporate Change & Alignment Teamwork HHS Strategy Map Vision:Leaders in exemplary care, innovation and academic excellence. Strategic Goals 1. We meet or exceed our communities’expectations. 2. We are internationally recognized for theexcellence of our patient-centred care,research and education. 3. We have a healthy work environment. • Strategic Goals • 4. We have a sound financial base to sustain our mission and achieve our vision. • 5. We create a sustainable and aligned system through action and leadership Patient, Family, Customer Perspective Fiduciary Perspective Priorities to Achieve Strategic Goals Internal Process Perspective Information Capital Mission:To provide excellent health care for the people and communities we serve and to advance health care through education and research. Values:RespectCaringInnovationAccountability HHS 2007/08

Introduction The Hamilton Health Sciences (HHS) Board Monitor provides a quarterly report on Key Quality and Performance Indicators. The latter have been identified by the Board of Trustees to reflect the Hospital’s five Strategic Goals. HHS has defined priorities to achieve these strategic goals:1. Access to Care: The timely access to health services is to achieve the best possible health outcomes. This includes a broad set of concerns that center on the degree to which needed services are available in a timely manner from the health care system. 2. Quality Initiatives: The extent to which health services for individuals and populations are provided in a manner that increases the likelihood of desired health outcomes and are consistent with current evidence and best practice. This area includes Patient Safety, Appropriateness of Care and Application of best Practices. 3. Operational Performance: The process of measuring, monitoring and adjusting organizational activity with the goal to optimize operational decisions and improve performance. This area includes initiatives related to efficiency and effectiveness. 4. Healthy People and Environments: The ability to create and sustain a positive work environment. This area includes initiatives related to staff attraction, retention, motivation, culture, safety, teamwork and leadership. 5. System Thinking and Leadership: The commitment to enhance the health care system through building and leveraging strategic relationships with other organizations and individuals in the public and private sectors (includes HHS Foundation). This area includes integration, innovation and knowledge transfer. The Board Monitor is organized by Strategic Goals and the Key Quality and Performance Indicators (KPI) reflect the performance within the Goals. Many of the Key Performance Indicators have benchmarks or targets assigned to them based on either industry rates, best practice and/or LHIN/Ministry targets.

Strategic Goal #1 We meet or exceed our communities’ expectations • Indicators: • Emergency Department Wait Times By Site – Quality Indicator • Target volumes/actuals – Performance Indicator • ALC Rates – Quality Indicator • Wait Time Strategy by Service – Quality Indicator

Emergency Department Wait Times By Triage Level Quality Indicator Wait Times are based on the time from Arrival to Departure for all visits to the Emergency Department (ambulatory and inpatient) by triage category. CTAS Codes: Triage 1: Resuscitation Triage 2: Emergent Triage 3: Urgent Triage 4: Less Urgent Triage 5: Non Urgent Source: HHS ADT/ED Meditech System HAPS Indicator

Target Volumes/Actuals Performance Indicator Source: HHS Data Repository HAPS Indicators

ALC Patient Trends Quality Indicator ALC rates are ALC days as proportion of patient days. LHIN #4 baseline is 2005/06 rate and 2007/08 LHIN #4 target is based on a 2% proposed improvement by March 2008 ALC patients are those waiting for an Alternate Level of Care, as defined by CIHI guidelines, Source: HHS ADT Meditech System

Wait Time Information Strategy: Wait Times - Quality Indicator Red: above the LHIN #4 mean and provincial mean. Yellow: Equal to or below LHIN #4 mean and above provincial mean or above LHIN and below Prov. Green: Equal to or less than LHIN #4 mean and equal to or below provincial mean. Source: Provincial Wait Times Strategy web site

Wait Time Information Strategy: Wait Times - Quality Indicator Red: above the LHIN #4 mean and provincial mean. Yellow: Equal to or below LHIN #4 mean and above provincial mean or above LHIN and below Prov. Green: Equal to or less than LHIN #4 mean and equal to or below provincial mean.

Strategic Goal #2 We are internationally recognized for the excellence of our patient-centered care, research and education • Indicators: • Infection Rates – Quality Indicator • Hospital Standardized Mortality Rates (HSMR) – Quality Indicator • Dollars Spent on Research – Performance Indicator

Infections Rates – Nosocomial VRE Rate per 1000 Patient Days Quality Indicator • VRE-Vancomycin Resistant Enterococcus A nosocomial incidence is defined as one which occurs 48 hours after admission to the facility. Rates are calculated per 1,000 patient days. HHS measures against itself as a target. Source: Infection Control Database – Antibiotic resistant organisms (ARO’s)

Infections Rates – Nosocomial C-Difficile Rate per 1000 Patient Days Quality Indicator • C Difficile - Clostridium difficile A nosocomial incidence is defined as one which occurs 48 hours after admission to the facility. Rates are calculated per 1,000 patient days. HHS measures against itself as a target Source: Infection Control Database

Infections Rates – Nosocomial MRSA Rate per 1000 Patient Days Quality Indicator • MRSA - Methicillin Resistant Staphylococus aureus . A nosocomial incidence is defined as one which occurs 48 hours after admission to the facility. Rates are calculated per 1,000 patient days. HHS measures against itself as a target Source: Infection Control Database – Antibiotic resistant organisms (ARO’s)

Hospital Standardized Mortality Ratio (HSMR) Quality Indicator Upper Limit HSMR is the ratio of observed to expected deaths. The calculation of expected deaths is based on weights (coefficients) derived from a logistic regression (LR) model. It is adjusted for age, sex, length of stay and admission category (transfers-in and co-morbidities). Annually an adjustment is made to exclude both palliative care patients and neonates less than 750 grams but not quarterly. It is also adjusted for the patient’s Charlson Index score, which reflects co-morbidities during a patient’s stay. The main purpose of HSMR ratios are to follow progress over time for an organization. Technically and statistically, CIHI cannot provide a separate HSMR for paediatric patients. MUMC reflects a combined results of both the adults and children population. Source: CIHI HSMR Reports HSMR ratio is number of observed deaths/number of expected deaths X 100 and is used to assess a Hospital’s mortality rate. CIHI HSMR Corporate rates not available until February 2008

Research Expenditures Presentation Pending – working with Research to determine an appropriate indicator Board Monitor

Strategic Goal #3 We have a healthy work environment • Indicators: • Vacancy Counts – Performance Indicator • External Staff Turnover – Performance Indicator • Absenteeism Rates- Performance Indicator

Vacancy Counts As at end of month based on unfilled postings Performance Indicator This indicator is a work in progress – focus for the future will be on critical positions and the time to fill them. Source: HRMS Peoplesoft Recruitment Module – based on number days the recruitment request has been posted

External Turnover Rates Performance Indicator External: Number of staff who have left the organization over average employee count per month. Source: HRMS Peoplesoft

Absenteeism Rate Performance Indicator Sick Hours Paid as a Percentage of Total Paid Hours This indicator is a HAPS indicator and is a percentage of sick time hours to total earned hours Source: Peoplesoft Time and Labour Payroll

Strategic Goal #4 We have a sound financial base to sustain our mission and achieve our vision • Indicators: • Total Margin and Current Ratio – Performance Indicator • Cost per Weighted Case Trend – Performance Indicator • Capital Projects (TBD) – Performance Indicator

Total Margin and Current Ratio Performance Indicator Summary: Calculated for HAPS definition: Current Assets/Current Liabilities (excludes deferred contributions) without adjustments for timing of MOH payments. Total Margin is Consolidated Total Surplus(Deficit)/Total Revenues (before Building depreciation, net of amortized grants and excluding recoveries).

Cost per Weighted Case Trend Performance Indicator Source: MOHLTC OCDM Methodology. The numerator is based on Acute Inpatient and SDS costs and the denominator is Acute Inpatient and Qualifying SDS PAC10 Weighted Cases. Trendline is 4% inflation

Capital Projects Work in Progress

Strategic Goal #5 We create a sustainable and aligned system through action and leadership • Indicators: • Work in Progress

Board Monitor – Quarterly Report