Quality of Care – Quarterly Report

1. Quality of Care – Quarterly Report Key Quality Indicators March 2008

2. 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 11

3. 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

4. Introduction The Hamilton Health Sciences (HHS) Quality of Care Report provides a quarterly report on Key Quality Indicators. They have been identified by the Quality Committee of the Board and grouped, where appropriately into the five Strategic Goals. The goal of the Operational Performance has measures captured in the Board Performance Monitor 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. Many of the Quality Indicators have benchmarks or targets assigned to them based on either industry rates, best practice and/or LHIN/Ministry targets.

5. Strategic Goal #1 We meet or exceed our communities’ expectations • Indicators: • Emergency Department Wait Times By Site • ALC Rates • Wait Time Strategy by Service

6. Emergency Department Wait Times By Triage Level 1, 2 and 3 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 Source: HHS ADT/ED Meditech System HAPS Indicator

7. Emergency Department Wait Times By Triage Level 4 , 5 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 4: Less Urgent Source HHS ADT/ED Meditech System Triage 5: Non Urgent HAPS Indicator

8. ALC Patient Trends 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

9. Wait Time Information Strategy: Wait Times 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

10. Wait Time Information Strategy: Wait Times 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

11. Wait Time Information Strategy: Wait Times 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.

12. Strategic Goal #2 We are internationally recognized for the excellence of our patient-centered care, research and education • Indicators: • Infection Rates • Hospital Standardized Mortality Rates (HSMR)

13. Infections Rates – Nosocomial VRE Rate per 1000 Patient Days • VRE-Vancomycin Resistant Enterococcus Rate per 1000 Pt.days 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)

14. Infections Rates – Nosocomial C-Difficile Rate per 1000 Patient Days • C Difficile - Clostridium difficile Rate per 1000 Pt.days 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

15. Infections Rates – Nosocomial MRSA Rate per 1000 Patient Days • 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)

16. 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 available up to and including September 2007