Hospital Service Accountability Agreement. Indicator Technical Specifications

Transcription

1 Hospital Service Accountability Agreement Indicator Technical Specifications October 2017

2 TABLE OF CONTENTS PATIENT EXPERIENCE ACCESS, EFFECTIVE, SAFE, PERSON-CENTERED... 5 PERFORMANCE th Percentile Emergency Department Length of Stay for Non-Admitted High Acuity (CTAS I-III) Patients th Percentile Emergency Department Length of Stay for Non-Admitted Low Acuity (CTAS IV-V) Patients... 8 Percent of Priority 2, 3 and 4 Cases Completed within Access Targets for Hip Replacements Percent of Priority 2, 3 and 4 Cases Completed within Access Targets for Knee Replacements Percent of Priority 2, 3 and 4 Cases Completed within Access Targets for MRI Percent of Priority 2, 3 and 4 Cases Completed within Access Targets for CT Scans Rate of Hospital Acquired Clostridium Difficile Infections Readmissions to Own Facility within 30 Days for Selected HBAM Inpatient Grouper (HIG) Conditions EXPLANATORY th Percentile Time to Disposition Decision (Admitted Patients) Percent of Stroke/TIA Patients Admitted to a Stroke Unit During Their Inpatient Stay Hospital Standardized Mortality Ratio (HSMR) Rate of Ventilator-Associated Pneumonia Central Line Infection Rate Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus Bacteremia Percent of Priority 2, 3, and 4 cases Completed within Access Targets for Cardiac By-Pass Surgery Percent of Priority 2, 3, and 4 cases Completed within Access Targets for Cancer Surgery Percent of Priority 2, 3 and 4 Cases Completed within Access Targets for Cataract Surgery ORGANIZATIONAL HEALTH - EFFICIENT, APPROPRIATELY RESOURCED, EMPLOYEE EXPERIENCE, GOVERNANCE PERFORMANCE Current Ratio (Consolidated all sector codes and fund types) Total Margin (Consolidated all sector codes and fund types) EXPLANATORY Total Margin (Hospital Sector Only) Adjusted Working Funds / Total Revenue % SYSTEM PERSPECTIVE INTEGRATION, COMMUNITY ENGAGEMENT, EHEALTH PERFORMANCE Alternate Level of Care (ALC) Rate EXPLANATORY Percentage of Alternate Level of Care (ALC) Days Repeat Unscheduled Emergency Visits Within 30 Days for Mental Health Conditions Repeat Unscheduled Emergency Visits Within 30 Days for Substance Abuse Conditions /19 H-SAA Technical Specifications Page 2

3 APPENDIX: SERVICE VOLUME METRICS CLINICAL ACTIVITY AND PATIENT SERVICES (SCHEDULE C2) Ambulatory Care Visits Complex Continuing Care Weighted Patient Days Day Surgery Weighted Cases Elderly Capital Assistance Program (ELDCAP) Inpatient Days ED Weighted Cases Emergency Department and Urgent Care Visits Inpatient Mental Health Days Inpatient Mental Health Weighted Days Inpatient Rehabilitation Days Total Inpatient Acute Weighted Cases OTHER GLOBAL VOLUMES TECHNICAL SPECIFICATIONS Rehabilitation Separations HOSPITAL SPECIALIZED SERVICES Cochlear Implants (Cases) Sexual Assault/Domestic Violence Treatment Clinics (Patients) WAIT TIME VOLUMES General Surgery (Base & incremental) Paediatric Surgery (Base & incremental) Hip & Knee Replacement - Revisions (Cases) Magnetic Resonance Imaging (MRI) Total Hours Ontario Breast Screening Program (OBSP) Magnetic Resonance Imaging (MRI) Total Hours Computed Tomography (CT) Total Hours PROVINCIAL PROGRAMS Automatic Inplantable Cardiac Defib's (# of New Implants) Bariatric Surgery (Procedures) Forensic Bed Inventory QUALITY BASED PROCEDURES Congestive Heart Failure (CHF) Acute Inpatient Stroke Endovascular Treatment (EVT) Stroke - Hemorrhage Stroke Ischemic or Unspecified Stroke Transient Ischemic Attack (TIA) Non-Cardiac Vascular Aortic Aneurysm (AA) Non-Cardiac Vascular Lower Extremity Occlusive Disease (LEOD) Acute Primary Unilateral Hip Replacement Inpatient Rehab for Primary Unilateral Hip Replacement Acute Primary Unilateral Knee Replacement Inpatient Rehab for Primary Unilateral Knee Replacement Acute Primary Bilateral Joint Replacement (Hip/Knee) Inpatient Rehab Primary Bilateral Joint Replacement (Hip/Knee) /19 H-SAA Technical Specifications Page 3

4 Hip Fracture Knee Arthroscopy Tonsillectomy Chronic Obstructive Pulmonary Disease (COPD) Pneumonia Cataract /19 H-SAA Technical Specifications Page 4

5 PATIENT EXPERIENCE Access, Effective, Safe, Person-Centered Performance INDICATOR NAME 90TH PERCENTILE EMERGENCY DEPARTMENT LENGTH OF STAY FOR NON- ADMITTED HIGH ACUITY (CTAS I-III) PATIENTS Detailed description of indicator INDICATOR CLASSIFICATION PERFORMANCE STANDARD Total time elapsed from triage or registration (whichever is earlier) to patient left ED for nonadmitted high acuity (CTAS I-III) patients. Performance Target: Provincial target of 8 hours Corridor: Upper corridor = performance target + 10% (8.8 hours) CALCULATION [Date/time Patient Left ED - Triage/Registration Date/time] - [CDULOS] National Ambulatory Care Reporting System (NACRS), Canadian Institute for Health Information (CIHI) Includes: 1. CTAS Level I, II, or III NUMERATOR Excludes: 1. Cases where Patient Left ED date/time are blank/unknown (9999) 2. Cases where patient has left without being seen by a physician during his/her visit (Disposition Code 02 or 03) 3. Cases where EDLOS is greater than or equal to 100,000 minutes (1,666 hours) Furthermore, cases are excluded from calculations if they fall in ANY ONE of the following exclusion criteria: 1. Cases where Registration date/time and Triage date/time are both blank/unknown (9999) 2. Cases where the MIS functional centre under Emergency Trauma, Observation, or Mental Health Services 3. Duplicate cases within the same functional centre where all ED data elements have the same values except for Abstract ID number 4. Cases where ED visit indicator is = "0" (i.e. scheduled ED visit) 2018/19 H-SAA Technical Specifications Page 5

6 DENOMINATOR GEOGRAPHY & TIMING CALCULATION TIMING/FREQUENCY OF RELEASE How often, and when, are data being released LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending LIMITATIONS Specific limitations Data are released quarterly, at the end of month, in April, July, October and January Data are available at the Local Health Integration Network (LHIN) and hospital levels Data are available from April 2008 A small percentage of records are excluded from the analysis every month due to missing/invalid values for the relevant wait time fields (such as Time patient left ER or Registration time etc.). Calculated indicator value is based on ER visits submitted by 126 sites participating in the ER NACRS Initiative (ERNI) database. Approximately 90% of ER visits in Ontario are captured by hospital sites participating in ERNI (based on NACRS 08/09 data released June 2009). ADDITIONAL INFORMATION COMMENTS Additional information regarding the calculation, interpretation, data source, etc. As of April 2009, a patient s stay in a designated Clinical Decision Unit (CDU) will be excluded in the total time spent in ER. Due to the introduction of newly designated CDUs in select hospitals, there may be a difference in the calculation methodology of the baseline and the quarterly indicators. Access to Care (ATC) Informatics regularly informs the LHINs of the CDU impact on the overall time spent in the ER through the monthly ER reports. LHINs are provided with the list of hospitals with designated CDUs. This data at the provincial level, for the latest month can be compared with the baseline of April 2008 in the Emergency Room Wait Times Government of Ontario website and in the ER Reports provided to LHIN s and hospitals every month (Provincial ER Highlights Report, ER LHIN Highlight Report and the LHIN ER Pay for Results Report). Historical trend data from April 2008 onwards for ERNI Reporting hospitals is available via the ATC Information Site and the Directory of Networks (DoN). If you do not have access to these 2018/19 H-SAA Technical Specifications Page 6

7 resources, data requests can be submitted to REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, RESPONSIBILITY FOR REPORTING DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) Cancer Care Ontario /19 H-SAA Technical Specifications Page 7

8 INDICATOR NAME 90TH PERCENTILE EMERGENCY DEPARTMENT LENGTH OF STAY FOR NON- ADMITTED LOW ACUITY (CTAS IV-V) PATIENTS Detailed description of indicator INDICATOR CLASSIFICATION PERFORMANCE STANDARD Total time elapsed from triage or registration (whichever is earlier) to patient left ED for nonadmitted low acuity (CTAS IV-V) patients. Performance Target: Provincial target of 4 hours Corridor: Upper corridor = performance target + 10% (4.4 hours) CALCULATION [Date/time Patient Left ED - Triage/Registration Date/time] - [CDULOS] National Ambulatory Care Reporting System (NACRS), Canadian Institute for Health Information (CIHI) Includes: 1. CTAS Level IV or V NUMERATOR Excludes: 1. Cases where Patient Left ED date/time are blank/unknown (9999) 2. Cases where patient has left without being seen by a physician during his/her visit (Disposition Code 02 or 03) 3. Cases where EDLOS is greater than or equal to 100,000 minutes (1,666 hours) Furthermore, cases are excluded from calculations if they fall in ANY ONE of the following exclusion criteria: 1. Cases where Registration date/time and Triage date/time are both blank/unknown (9999) 2. Cases where the MIS functional centre under Emergency Trauma, Observation, or Mental Health Services 3. Duplicate cases within the same functional centre where all ED data elements have the same values except for Abstract ID number 4. Cases where ED visit indicator is = "0" (i.e. scheduled ED visit) DENOMIN ATOR CALCULATION 2018/19 H-SAA Technical Specifications Page 8

9 GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending LIMITATIONS Specific limitations Data are released quarterly, at the end of month, in April, July, October and January Provincial, LHIN, Hospital Data are available from April 2008 A small percentage of records are excluded from the analysis every month, due to missing/invalid values for the relevant wait time fields (such as Time patient left ER or Registration time etc.). Calculated indicator value is based on ER visits submitted participating sites in the ER National Ambulatory Care Reporting System Initiative (ERNI) reporting to the NACRS database. Approximately 90% of ER visits in Ontario are captured by hospital sites participating in ERNI ADDITIONAL INFORMATION COMMENTS Additional information regarding the calculation, interpretation, data source, etc. As of April 2009, a patient s stay in a designated Clinical Decision Unit (CDU) will be excluded in the total time spent in ER. Due to the introduction of newly designated CDUs in select hospitals, there may be a difference in the calculation methodology of the baseline and the quarterly indicators. Access to Care (ATC) Informatics regularly informs the LHINs of the CDU impact on the overall time spent in the Emergency Department through the monthly ER reports. LHINs are provided with the list of hospitals with designated CDUs. This data at the provincial level, for the latest month can be compared with the baseline of April 2008 in the Emergency Room Wait Times Government of Ontario website and in the ER Reports provided to LHIN s and hospitals every month (Provincial ER Highlights Report, ER LHIN Highlight Report and the LHIN ER Pay for Results Report). Historical trend data from April 2008 onwards for ERNI Reporting hospitals is available via the ATC Information Site and the Directory of Networks (DoN). If you do not have access to these resources, data requests can be submitted to ATCDataRequest@cancercare.on.ca. 2018/19 H-SAA Technical Specifications Page 9

10 REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, RESPONSIBILITY FOR REPORTING DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) Cancer Care Ontario /19 H-SAA Technical Specifications Page 10

11 INDICATOR NAME Detailed description of indicator PERCENT OF PRIORITY 2, 3 AND 4 CASES COMPLETED WITHIN ACCESS TARGETS FOR HIP REPLACEMENTS Descriptions of priority levels can be found in the link within the Reference section. INDICATOR CLASSIFICATION PERFORMANCE STANDARD Performance Target: (i) For hospitals performing at the provincial target or better: Performance target = maintain or improve current performance. Historical performance should be reviewed prior to target setting, and plans to maintain or improve the performance target are to be discussed. (ii) For hospitals performing below provincial target: Performance target= provincial target or better. Historical performance should be reviewed prior to target setting, and plans to achieve the performance target are to be discussed. INDICATOR CALCULATION Corridor: Greater than or equal to the performance target to 100%. Step 1: Count the total number of cases completed for the reporting period by priority level (Priority 2, 3 and 4). Please refer to the inclusion/exclusion criteria listed below. Step 2: Of the total count in step 1, count the number of cases where wait times are less than or equal to the provincial targets. Do this for all of the three priority levels (Priority 2, 3, and 4). Step 3: The weighted percent of cases completed within Priority 2, 3 and 4 access targets = sum of the counts by Priority in step 2 divided by the sum of the counts by Priority in step 1 x 100 to get the percentage. Sample calculation: WTIS, ATC, Cancer Care Ontario. 2018/19 H-SAA Technical Specifications Page 11

12 GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending Access to Care has implemented a robust data quality and compliance framework to assess data quality under four key dimensions: timeliness, validity, reliability and usability. The complete framework is available in the Wait Time Conditions of Funding and further information is available upon request at: ATCsupport@cancercare.on.ca. All closed wait list entries with procedure dates within date range submitted by hospitals through the WTIS. Patient age greater than or equal to 18 years old on the day the procedure was completed. Procedures no longer required (or cancelled cases) are excluded from wait time calculation. Procedures assigned as priority level 1 cases are excluded from wait time calculation. Cases with missing priority levels are also excluded. Wait list entries identified by hospitals as data entry errors are excluded. If unavailable days fall outside the decision to treat date up to procedure date, unavailable days are not deducted from patients wait days. These are considered data entry errors. As part of ATC s on-going data quality and compliance processes with hospitals, accuracy is one of the key areas that have been monitored closely over time and assessed on a regular basis along with other data quality dimensions. ATC monitors data quality with hospitals on a weekly basis and works closely with hospitals WTIS coordinators to ensure data quality indicators and thresholds are met. If hospitals have challenges meeting data quality thresholds they may be excluded from wait time reporting calculations as well as public reporting. In these circumstances hospital, LHIN and/or ministry leadership is engaged to ensure hospital data quality is enhanced to become reportable as soon as possible. The calculated percent of cases completed within priority target can be compared with the historical trend published in the Government of Ontario wait time s website. All inclusions/exclusions criteria used are similar. Also, historical wait times trend for low volume hospitals/lhins will show as NV (no or low volume) instead of a calculated percent of cases completed within priority target. ADDITIONAL INFORMATION LIMITATIONS Specific limitations COMMENTS Additional information regarding the calculation, Hospitals submitting wait time data voluntarily (not required to report) are included in wait time calculation. Calculated percent of cases completed within priority targets is based only on the number of cases entered in the system. Logically, hospitals not reporting cases promptly are excluded at the 2018/19 H-SAA Technical Specifications Page 12

13 interpretation, data source, etc. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, RESPONSIBILITY FOR REPORTING time of data extraction. Volumes submitted by hospitals are checked monthly for completeness. Hospital volume is compared against the expected monthly average. Outliers are validated with hospitals if the wait days are not accurate. px Cancer Care Ontario DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) /19 H-SAA Technical Specifications Page 13

14 INDICATOR NAME Detailed description of indicator PERCENT OF PRIORITY 2, 3 AND 4 CASES COMPLETED WITHIN ACCESS TARGETS FOR KNEE REPLACEMENTS Descriptions of priority levels can be found in the link within the Reference section. INDICATOR CLASSIFICATION PERFORMANCE STANDARD Performance Target: (i) For hospitals performing at the provincial target or better: Performance target = maintain or improve current performance. Historical performance should be reviewed prior to target setting, and plans to maintain or improve the performance target are to be discussed. (ii) For hospitals performing below provincial target: Performance target= provincial target or better. Historical performance should be reviewed prior to target setting, and plans to achieve the performance target are to be discussed. INDICATOR CALCULATION Corridor: Greater than or equal to the performance target to 100%. Step 1: Count the total number of cases completed for the reporting period by priority level (Priority 2, 3 and 4). Please refer to the inclusion/exclusion criteria listed below. Step 2: Of the total count in step 1, count the number of cases where wait times are less than or equal to the provincial targets. Do this for all of the three priority levels (Priority 2, 3, and 4). Step 3: The weighted percent of cases completed within Priority 2, 3 and 4 access targets = sum of the counts by Priority in step 2 divided by the sum of the counts by Priority in step 1 x 100 to get the percentage. Sample calculation: WTIS, ATC, Cancer Care Ontario. 2018/19 H-SAA Technical Specifications Page 14

15 Access to Care has implemented a robust data quality and compliance framework to assess data quality under four key dimensions: timeliness, validity, reliability and usability. The complete framework is available in the Wait Time Conditions of Funding and further information is available upon request at: ATCsupport@cancercare.on.ca. All closed wait list entries with procedure dates within date range submitted by hospitals through the WTIS. Patient age greater than or equal to 18 years old on the day the procedure was completed. Procedures no longer required (or cancelled cases) are excluded from wait time calculation. Procedures assigned as priority level 1 cases are excluded from wait time calculation. Cases with missing priority levels are also excluded. Wait list entries identified by hospitals as data entry errors are excluded. If unavailable days fall outside the decision to treat date up to procedure date, unavailable days are not deducted from patients wait days. These are considered data entry errors. TIMING/FREQUENCY OF RELEASE How often, and when, are data being released GEOGRAPHY & TIMING ADDITIONAL INFORMATION LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending LIMITATIONS Specific limitations COMMENTS Additional information regarding the calculation, As part of ATC s on-going data quality and compliance processes with hospitals, accuracy is one of the key areas that have been monitored closely over time and assessed on a regular basis along with other data quality dimensions. ATC monitors data quality with hospitals on a weekly basis and works closely with hospitals WTIS coordinators to ensure data quality indicators and thresholds are met. If hospitals have challenges meeting data quality thresholds they may be excluded from wait time reporting calculations as well as public reporting. In these circumstances hospital, LHIN and/or ministry leadership is engaged to ensure hospital data quality is enhanced to become reportable as soon as possible. The calculated percent of cases completed within priority target can be compared with the historical trend published in the Government of Ontario wait time s website. All inclusions/exclusions criteria used are similar. Also, historical wait times trend for low volume hospitals/lhins will show as NV (no or low volume) instead of a calculated percent of cases completed within priority target. Hospitals submitting wait time data voluntarily (not required to report) are included in wait time calculation. Calculated percent of cases completed within priority targets is based only on the number of cases entered in the 2018/19 H-SAA Technical Specifications Page 15

16 interpretation, data source, etc. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, RESPONSIBILITY FOR REPORTING system. Logically, hospitals not reporting cases promptly are excluded at the time of data extraction. Volumes submitted by hospitals are checked monthly for completeness. Hospital volume is compared against the expected monthly average. Outliers are validated with hospitals if the wait days are not accurate. px Cancer Care Ontario DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) /19 H-SAA Technical Specifications Page 16

17 INDICATOR NAME Detailed description of indicator PERCENT OF PRIORITY 2, 3 AND 4 CASES COMPLETED WITHIN ACCESS TARGETS FOR MRI Descriptions of priority levels can be found in the link within the Reference section. INDICATOR CLASSIFICATION PERFORMANCE STANDARD Performance Target: (i) For hospitals performing at the provincial target or better: Performance target = maintain or improve current performance. Historical performance should be reviewed prior to target setting, and plans to maintain or improve the performance target are to be discussed. (ii) For hospitals performing below provincial target: Performance target= provincial target or better. Historical performance should be reviewed prior to target setting, and plans to achieve the performance target are to be discussed. INDICATOR CALCULATION Corridor: Greater than or equal to the performance target to 100%. Step 1: Count the total number of cases completed for the reporting period by priority level (Priority 2, 3 and 4). Please refer to the inclusion/exclusion criteria listed below. Step 2: Of the total count in step 1, count the number of cases where wait times are less than or equal to the provincial targets. Do this for all of the three priority levels (Priority 2, 3, and 4). Step 3: The weighted percent of cases completed within Priority 2, 3 and 4 access targets = sum of the counts by Priority in step 2 divided by the sum of the counts by Priority in step 1 x 100 to get the percentage. Sample calculation: 2018/19 H-SAA Technical Specifications Page 17

18 Wait Time Information System (WTIS), Access to Care (ATC), Cancer Care Ontario. GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending Access to Care has implemented a robust data quality and compliance framework to assess data quality under four key dimensions: timeliness, validity, reliability and usability. The complete framework is available in the Wait Time Conditions of Funding and further information is available upon request at: ATCsupport@cancercare.on.ca. All closed wait list entries with procedure dates within date range submitted by hospitals through the Wait Time Information System. Patient age greater than or equal to 18 years old on the day the procedure was completed. Procedures no longer required (or cancelled cases) are excluded from wait time calculation. Procedures assigned as priority level 1 cases are excluded from wait time calculation. Cases with missing priority levels are also excluded. Wait list entries identified by hospitals as data entry errors are excluded. If unavailable days fall outside the decision to treat date up to procedure date, unavailable days are not deducted from patients wait days. These are considered data entry errors. Diagnostic Imaging (DI) cases classified as specified date procedures (timed procedures) are excluded from wait time calculation. As part of ATC s on-going data quality and compliance processes with hospitals, accuracy is one of the key areas that have been monitored closely over time and assessed on a regular basis along with other data quality dimensions. ATC monitors data quality with hospitals on a weekly basis and works closely with hospitals WTIS coordinators to ensure data quality indicators and thresholds are met. If hospitals have challenges meeting data quality thresholds they may be excluded from wait time reporting calculations as well as public reporting. In these circumstances hospital, LHIN and/or ministry leadership is engaged to ensure hospital data quality is enhanced to become reportable as soon as possible. The calculated percent of cases completed within priority target can be compared with the historical trend published in the Government of Ontario wait time s website. All inclusions/exclusions criteria used are similar. Also, historical wait times trend for low volume hospitals/lhins will show as NV (no or low volume) instead of a calculated percent of cases completed within priority target. 2018/19 H-SAA Technical Specifications Page 18

19 ADDITIONAL INFORMATION LIMITATIONS Specific limitations COMMENTS Additional information regarding the calculation, interpretation, data source, etc. Hospitals submitting wait time data voluntarily (not required to report) are included in wait time calculation. Calculated percent of cases completed within priority targets is based only on the number of cases entered in the system. Logically, hospitals not reporting cases promptly are excluded at the time of data extraction. Volumes submitted by hospitals are checked monthly for completeness. Hospital volume is compared against the expected monthly average. Outliers are validated with hospitals if the wait days are not accurate. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, RESPONSIBILITY FOR REPORTING DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) px Cancer Care Ontario /19 H-SAA Technical Specifications Page 19

20 INDICATOR NAME PERCENT OF PRIORITY 2, 3 AND 4 CASES COMPLETED WITHIN ACCESS TARGETS FOR CT SCANS Detailed description of indicator Descriptions of priority levels can be found in the link within the Reference section. INDICATOR CLASSIFICATION Performance Target: (i) For hospitals performing at the provincial target or better: Performance target = maintain or improve current performance. Historical performance should be reviewed prior to target setting, and plans to maintain or improve the performance target are to be discussed. PERFORMANCE STANDARD (ii) For hospitals performing below provincial target: Performance target= provincial target or better. Historical performance should be reviewed prior to target setting, and plans to achieve the performance target are to be discussed. INDICATOR CALCULATION Corridor: Greater than or equal to the performance target to 100%. Step 1: Count the total number of cases completed for the reporting period by priority level (Priority 2, 3 and 4). Please refer to the inclusion/exclusion criteria listed below. Step 2: Of the total count in step 1, count the number of cases where wait times are less than or equal to the provincial targets. Do this for all of the three priority levels (Priority 2, 3, and 4). Step 3: The weighted percent of cases completed within Priority 2, 3 and 4 access targets = sum of the counts by Priority in step 2 divided by the sum of the counts by Priority in step 1 x 100 to get the percentage. Sample calculation: 2018/19 H-SAA Technical Specifications Page 20

21 Wait Time Information System (WTIS), Access to Care (ATC), Cancer Care Ontario. Access to Care has implemented a robust data quality and compliance framework to assess data quality under four key dimensions: timeliness, validity, reliability and usability. The complete framework is available in the Wait Time Conditions of Funding and further information is available upon request at: ATCsupport@cancercare.on.ca. All closed wait list entries with procedure dates within date range submitted by hospitals through the Wait Time Information System. Patient age greater than or equal to 18 years old on the day the procedure was completed. Procedures no longer required (or cancelled cases) are excluded from wait time calculation. Procedures assigned as priority level 1 cases are excluded from wait time calculation. Cases with missing priority levels are also excluded. Wait list entries identified by hospitals as data entry errors are excluded. If unavailable days fall outside the decision to treat date up to procedure date, unavailable days are not deducted from patients wait days. These are considered data entry errors. Diagnostic Imaging (DI) cases classified as specified date procedures (timed procedures) are excluded from wait time calculation. TIMING/FREQUENCY OF RELEASE How often, and when, are data being released GEOGRAPHY & TIMING LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending As part of ATC s on-going data quality and compliance processes with hospitals, accuracy is one of the key areas that have been monitored closely over time and assessed on a regular basis along with other data quality dimensions. ATC monitors data quality with hospitals on a weekly basis and works closely with hospitals WTIS coordinators to ensure data quality indicators and thresholds are met. If hospitals have challenges meeting data quality thresholds they may be excluded from wait time reporting calculations as well as public reporting. In these circumstances hospital, LHIN and/or ministry leadership is engaged to ensure hospital data quality is enhanced to become reportable as soon as possible. The calculated percent of cases completed within priority target can be compared with the historical trend published in the Government of Ontario wait time s website. All inclusions/exclusions criteria used are similar. Also, historical wait times trend for low volume hospitals/lhins will show as NV 2018/19 H-SAA Technical Specifications Page 21

22 (no or low volume) instead of a calculated percent of cases completed within priority target. ADDITIONAL INFORMATION LIMITATIONS Specific limitations COMMENTS Additional information regarding the calculation, interpretation, data source, etc. Hospitals submitting wait time data voluntarily (not required to report) are included in wait time calculation. Calculated percent of cases completed within priority targets is based only on the number of cases entered in the system. Logically, hospitals not reporting cases promptly are excluded at the time of data extraction. Volumes submitted by hospitals are checked monthly for completeness. Hospital volume is compared against the expected monthly average. Outliers are validated with hospitals if the wait days are not accurate. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, RESPONSIBILITY FOR REPORTING DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) px Cancer Care Ontario /19 H-SAA Technical Specifications Page 22

23 INDICATOR NAME RATE OF HOSPITAL ACQUIRED CLOSTRIDIUM DIFFICILE INFECTIONS Detailed description of indicator INDICATOR CLASSIFICATION PERFORMANCE STANDARD The rate of hospital acquired Clostridium difficile infections (CDI) is a measure of the incidence of disease and is the number of CDI cases per 1,000 patient days. Performance Target: 0 Corridor: Upper corridor = 10% improvement on current rate LHINs and hospitals should review current rates and identify achievable performance improvement or maintenance of current performance levels CALCULATION The total number of new nosocomial (i.e. hospital acquired) CDI cases in the reporting period multiplied by 1,000 Self Reporting Initiative (SRI), Ontario Ministry of Health and Long-Term Care (MOHLTC) NUMERATOR Includes: 1. All publicly funded hospitals 2. Inpatient beds 3. Laboratory-confirmed CDI cases (i.e. confirmation of a positive toxin assay (A/B) for Clostridium difficile together with diarrhea OR visualization of pseudomembranes on sigmoidoscopy or colonoscopy, or histological/pathological diagnosis of pseudomembranous colitis) 4. New nosocomial cases associated with the reporting facility is where the infection was not present on admission (i.e., onset of symptoms > 72 hours after admission) or the infection was present at the time of admission but was related to a previous admission to the same facility within the last 4 weeks and the case has not had CDI in the past 8 weeks. Excludes: 1. Patients less than 1 year of age 2. Long-term care beds 2018/19 H-SAA Technical Specifications Page 23

24 CALCULATION The total number of patient days spent in-hospital in a reporting period DENOMINATOR Self Reporting Initiative (SRI), Ontario Ministry of Health and Long-Term Care (MOHLTC) Includes: 1. All publicly funded hospitals 2. Inpatient beds Excludes: 1. Patients less than 1 year of age 2. Long-term care beds GEOGRAPHY & TIMING ADDITIONAL INFORMATION TIMING/FREQUENCY OF RELEASE How often, and when, are data being released E.g. Be as specific as possible..data are released annually in mid- May LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending LIMITATIONS Specific limitations COMMENTS Additional information regarding the calculation, interpretation, data source, etc. Data are available each month for the previous month s data. Data may be aggregated across reporting periods to generate more stable rates. Data are available at provincial, LHIN and hospital levels Data are available from September 2008 Data are self-reported by hospital No individual patient data are available, therefore indicator cannot be broken down by age, gender, income or education Baseline data should be generated on 1-years worth of data since CDI is expected to fluctuate seasonally Trending and comparisons are most valid by hospital type (e.g. small, large community, acute teaching, chronic care and rehab and mental health). This is in order to make limited adjustment for patient case mix. The CDI rate calculation allows the level of hospital activity to be taken into account because this will fluctuate over time and is different across hospitals. Hospital rates can also fluctuate significantly from one reporting 2018/19 H-SAA Technical Specifications Page 24

25 period to another for a variety of reasons. For example, a small hospital with relatively few patient days when compared to larger institutions could see its rates vary dramatically based on one or two cases in any given month. These types of fluctuations will level out over a longer period of time. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, RESPONSIBILITY FOR REPORTING Patient Safety Website Health Service Providers DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) /19 H-SAA Technical Specifications Page 25

26 INDICATOR NAME Detailed description of indicator INDICATOR CLASSIFICATION PERFORMANCE STANDARD READMISSIONS TO OWN FACILITY WITHIN 30 DAYS FOR SELECTED HBAM INPATIENT GROUPER (HIG) CONDITIONS Risk-adjusted readmission ratio to hospital for patients with an acute inpatient hospital stay for: Acute myocardial infarction; Cardiac conditions (excluding heart attack); Congestive heart failure; Chronic obstructive pulmonary disease; Pneumonia; Diabetes; Stroke; and, Gastrointestinal disease; Who, after discharge, may have a subsequent non-elective readmission within 30 days to the same hospital where the index visit occurred. Performance Target: A provincial target for this indicator has not been established. However, hospitals and LHINs should note that a provincial target for a related indicator (Readmissions within 30 days for selected HBAM Inpatient Grouper (HIG) conditions) exists and can be used to inform conversations on target setting. Historical performance should be reviewed prior to target setting, and plans to achieve, maintain or improve the performance target are to be discussed. Corridor: Upper corridor = performance target + 10% Numerator (Crude Rate) INDICATOR CALCULATION Inclusion/Exclusion Criteria Includes: 1. The hospitalization readmission is counted if: a. The readmission date is within 30 days of the index case discharge and is to the same hospital where the index visit occurred; b. the DAD field admission category is urgent; and, c. the admission is not coded as an acute transfer by receiving hospital (unless the readmission was coded as a transfer from the same hospital). Excludes: Records with missing or invalid discharge/admission date, health number, age and gender. 2018/19 H-SAA Technical Specifications Page 26

27 Calculation The numerator is the sum of all readmissions for all index cases in the reporting period. Steps: To obtain observed readmissions: 1. Index cases (denominator) must be identified first. 2. For each index case, identify whether there is a non-elective readmission to the same hospital within 30 days of discharge. The hospitalization readmission is counted if: a. The readmission date is within 30 days of the index case discharge; and, b. The DAD field admission category is urgent (non-elective readmission). The hospitalization readmission is excluded if: a. The readmission case is coded as an acute transfer by the receiving hospital (unless the readmission was coded as a transfer from the same hospital). b. There are missing or invalid data for discharge date, admission date, health number, age and gender. Numerator (Expected Rate) Calculation Expected Readmissions To Own: Multiple steps are used to calculate the predicted probability of non-elective readmission to the acute setting of the hospital where the index visit occurred for patients discharged with the specified HIGs. This expected readmission to own rate is based on the calculated propensity for readmission to own hospital: 1. The propensity for readmission to own is calculated first by hospital as the relative frequency of the number of readmissions to own hospital to the number of readmissions to any hospital (see Readmissions within 30 days for selected HBAM Inpatient Grouper (HIG) Conditions Indicator for inclusion/exclusion criteria for identifying readmissions to any). 2. Secondly, a logistic regression model is fitted with HIG, age, gender, prior hospitalizations (within 1, 2 and 3 months) at any Ontario acute care hospital, quarterly seasonality and the Charlson co-morbidity adjustment index score as independent variables. The dependent variable is readmission to any Ontario acute care hospital. Coefficients derived from the logistic model are used to calculate the probability of readmission to any hospital for each patient. 3. The probability of readmission to any hospital for each patient (in 2 above) is multiplied by the propensity for readmission to own 2018/19 H-SAA Technical Specifications Page 27

28 hospital (in 1. above). This produces the expected readmission to own value for each patient. 4. The expected number of readmissions to own for a hospital is the sum of the patient probabilities (in 3. above) for all the index admissions in that hospital. Denominator (Crude and Expected Rates) Inclusion/Exclusion Criteria Includes: 1. Patient with: Acute Myocardial Infarction (age 45+) Cardiac conditions other than heart attack (age 40+) Congestive heart failure (age 45+) Chronic obstructive pulmonary disease (age 45+) Pneumonia Diabetes Stroke (age 45+) Gastrointestinal disease (See table at the end of this section for included HIGs); 2. Cases where the Inpatient HIG atypical code is either 00 (typical cases), 01 (transfer in cases), 09 (short stay outlier cases), 10 (long stay outlier cases), or 11 (transfer in long stay cases). Excludes: 1. Records with missing valid data on discharge/admission date, health number, age and gender; 2. Index cases coded as transfers to another acute inpatient hospital, deaths, and sign-outs. 3. Exclude cases with Discharge disposition = 07 (death). Calculation The denominator is the sum of all index cases (discharges in the reporting period for selected HIGs). Steps: Identify index cases: 1. The index hospitalization is counted if: a. The discharge date falls in the reporting period; b. The HIG condition and patient age restrictions match those included in the list of conditions; c. The Inpatient HIG atypical code is 00 (typical cases), 01 (transfer in cases), 09 (short stay outlier cases), 10 (long stay outlier cases), or 11 (transfer in long stay cases). 2018/19 H-SAA Technical Specifications Page 28

29 2. The index hospitalization is excluded if: a. The case is coded as a transfer to another acute inpatient hospital. 3. The denominator is the sum of all index cases in the reporting period. Risk-adjusted Rate for Readmit to own Risk-adjusted rates for readmit to own are most valuable for comparisons within hospitals over time. Comparing across hospitals is limited by the exclusion of readmissions that occur at hospitals where the index visit did not occur. Calculation Risk adjusted rate = Crude readmission to own (observed, actual) rate x Provincial reference rate Expected readmission to own rate Interpretation A risk-adjusted readmission to own rate represents ahospital s would have been rate, if the hospital s population demographic, case mix, patient complexity, etc. were the same as the reference population (in this case, at the level of province i.e. Ontario). DAD, CIHI. See Calculation section above. GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released E.g. Be as specific as possible..data are released annually in mid- May LEVELS OF COMPARABILITY Levels of geography for comparison Interim data are used in order to provide timely (quarterly) performance results. (See Limitations, below). 2018/19 H-SAA Technical Specifications Page 29

30 TRENDING Years available for trending Data are available for the most recent 4 years. LIMITATIONS Specific limitations There are data quality and completeness issues with interim data. Indicator values may change substantially once complete data are analyzed (versus analysis based on interim potentially incomplete quarterly data). COMMENTS ADDITIONAL INFORMATION Additional information regarding the calculation, interpretation, data source, etc. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, RESPONSIBILITY FOR REPORTING Health Analytics Branch DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) List of conditions: List of Eligible Conditions (HIGs) HIG HIG Description Acute Myocardial Infarction (Age 45) 193a Myocardial Infarction/Shock/Arrest with Coronary Angiogram 193b Myocardial Infarction/Shock/Arrest with Coronary Angiogram with Comorbid Cardiac Conditions 194a Myocardial Infarction/Shock/Arrest without Coronary Angiogram 2018/19 H-SAA Technical Specifications Page 30

31 194b Myocardial Infarction/Shock/Arrest without Coronary Angiogram with Comorbid Cardiac Conditions Stroke (Age 45) 25 Hemorrhagic Event of Central Nervous System 26 Ischemic Event of Central Nervous System 28 Unspecified Stroke COPD (Age 45) 139c Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection 139d Chronic Obstructive Pulmonary Disease without Lower Respiratory Infection Pneumonia (All ages) 136 Bacterial Pneumonia 138 Viral/Unspecified Pneumonia 143 Disease of Pleura Congestive Heart Failure (Age 45) 196 Heart Failure without Coronary Angiogram Diabetes (All ages) 437a Diabetes, Other 437b Diabetes with renal complications 437c Diabetes with ophthalmic, neurological, or circulatory complications 437d Diabetes with multiple complications Cardiac (Age 40) 202 Arrhythmia without Coronary Angiogram 204a Unstable Angina/Atherosclerotic Heart Disease without Coronary Angiogram 204b Unstable Angina/Atherosclerotic Heart Disease without Coronary Angiogram with Comorbid Cardiac Conditions 208a 208b Angina (except Unstable)/Chest Pain without Coronary Angiogram Angina (except Unstable)/Chest Pain without Coronary Angiogram with Comorbid Cardiac Conditions Gastrointestinal (All ages) 231 Minor Upper Gastrointestinal Intervention 248 Severe Enteritis 251 Complicated Ulcer 253 Inflammatory Bowel Disease 254 Gastrointestinal Hemorrhage 255 Gastrointestinal Obstruction 256 Esophagitis/Gastritis/Miscellaneous Digestive Disease 257 Symptom/Sign of Digestive System 258 Other Gastrointestinal Disorder 285 Cirrhosis/Alcoholic Hepatitis 286 Liver Disease except Cirrhosis/Malignancy 287 Disorder of Pancreas except Malignancy 288 Disorder of Biliary Tract 2018/19 H-SAA Technical Specifications Page 31

32 Explanatory INDICATOR DESCRIPTION INDICATOR NAME Detailed description of indicator INDICATOR CLASSIFICATION 90TH PERCENTILE TIME TO DISPOSITION DECISION (ADMITTED PATIENTS) Total time elapsed from triage or registration (whichever is earlier) to disposition decision Explanatory CALCULATION [ED disposition date/time - ED Triage/Registration Date/time (whichever is earlier / valid)] TBD Includes: 1. Disposition code NUMERATOR Excludes: 1. Cases where Cases where Disposition Date/Time is unknown (9999) or blank 2. Cases where patient has left without being seen by a physician during his/her visit (Disposition Code 02 & 03) 3. Time to Disposition Decision is greater than or equal to minutes (1666 hours) Furthermore, cases are excluded from calculations if they fall in ANY ONE of the following exclusion criteria: 1. Cases where Registration date/time and Triage date/time are both blank/unknown (9999) 2. Cases where the MIS functional centre under Emergency Trauma, Observation, or Mental Health Services 3. Duplicate cases within the same functional centre where all ED data elements have the same values except for Abstract ID number 4. Cases where ED visit indicator is = "0" (i.e. scheduled ED visit) DENOMINATOR CALCULATION 2018/19 H-SAA Technical Specifications Page 32

33 GEOGRAPHY & TIMING ADDITIONAL INFORMATION TIMING/FREQUENCY OF RELEASE How often, and when, are data being released LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending LIMITATIONS Specific limitations COMMENTS Additional information regarding the calculation, interpretation, data source, etc. TBD TBD TBD TBD TBD REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, RESPONSIBILITY FOR REPORTING DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) Cancer Care Ontario /19 H-SAA Technical Specifications Page 33

34 INDICATOR NAME Detailed description of indicator INDICATOR CLASSIFICATION PERCENT OF STROKE/TIA PATIENTS ADMITTED TO A STROKE UNIT DURING THEIR INPATIENT STAY All stroke/tia patients should be admitted to a stroke unit for acute stroke management for improved outcomes Explanatory Stroke/TIA Patients (Most Responsible Diagnosis = I60, I61, I63, I64, G45, H34.0, H34.1) admitted to a Stroke unit at any point during their inpatient stay, multiplied by 100 NUMERATOR CALCULATION A stroke unit is a geographical unit with identifiable co-located beds (e.g., 5A-7, 5A-8, 5A-9) that are occupied by stroke patients 75% of the time and has a dedicated interprofessional team with expertise in stroke care including, at a minimum, nursing, physiotherapy, occupational therapy and speech-language pathology. Ontario Stroke Registry, Ontario Stroke Audit Hospitals participating in CIHI Special Project #340 via the Discharge Abstract Database (DAD), Canadian Institute for Health Information (CIHI) Excludes: 1. Diagnostic code G45.4, I63.6, I60.8 CALCULATION Stroke/TIA Patients (Most Responsible Diagnosis = I60, I61, I63, I64, G45, H34.0, H34.1) admitted Ontario Stroke Registry, Ontario Stroke Audit DENOMINATOR Hospitals participating in CIHI Special Project #340 via the DAD, CIHI Excludes: 1. Diagnostic code excludes I63.6, I60.8, G Patients with palliative measures as part of the initial treatment plan. 3. OSA: In-hospital strokes 4. OSA 2012/13 excludes Subarachnoid hemorrhages. Includes adult patients only (18 and over) GE OG TIMING/FREQUENCY OF RELEASE Data are available from Ontario Stroke Audit 2018/19 H-SAA Technical Specifications Page 34

35 How often, and when, are data being released E.g. Be as specific as possible..data are released annually in mid- May LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending Data are available annually in December for all hospitals beginning in 2012/13. Data are available at the level of the facility LHIN Data are available as of 2004 LIMITATIONS Specific limitations There may be limitations as a result of the DAD being the only data source ADDITIONAL INFORMATION COMMENTS Additional information regarding the calculation, interpretation, data source, etc. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, RESPONSIBILITY FOR REPORTING The Ontario Stroke Network s Ontario Stroke Report Cards report stroke unit at a population level. Analysis is based on a patient s postal code, not facility. 1. Canadian Best Practices SU section ( 2. QBP Handbook ( page 91) 3. Ontario Stroke Report Cards, indicator 8 ( Stroke-Report-Cards) ICES DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) /19 H-SAA Technical Specifications Page 35

36 INDICATOR NAME HOSPITAL STANDARDIZED MORTALITY RATIO (HSMR) The hospital standardized mortality ratio (HSMR) is a big-dot summary measure that is used to track a hospital s mortality over time. The HSMR is a tool that allows hospitals to measure and monitor their progress in quality of care. HSMR is a ratio of the actual number of in-hospital deaths in a region or hospital to the number that would have been expected based on the types of patients a region or hospital treats. It focuses on the diagnosis groups that account for the majority of in-hospital deaths. Detailed description of indicator Observed deaths HSMR= x 100 Expected deaths Using a logistic regression model, HSMR is adjusted for several factors that affect in-hospital mortality, including age, sex, length of stay, admission category, diagnosis group, co morbidity and transfer from another acute care institution. A ratio equal to 100 suggests that there is no difference between a local mortality rate and the average national experience, given the types of patients cared for. An HSMR greater or less than 100 suggests that a local mortality rate is higher or lower, respectively, than the national experience. The confidence intervals describe the precision of the HSMR estimate. HSMR values are estimated to be accurate within the upper and lower confidence interval, 19 times out of % confidence interval is calculated using Byar s approximation. A confidence interval that includes 100 suggests that the HSMR is not statistically different from the baseline of 100. HSMR results whose confidence interval does not include 100 are statistically different from the baseline. INDICATOR CLASSIFICATION Explanatory NUMERATOR CALCULATION Observed deaths, or actual number of in-hospital deaths that occurred in a hospital or region (among patients who satisfy HSMR inclusion and exclusion criteria). Discharge Abstract Database (DAD), Hospital Morbidity Database (HMDB), Canadian Institute of Health Information (CIHI) 2018/19 H-SAA Technical Specifications Page 36

37 Inclusion criteria: 1. Discharge between April 1 of a given year and March 31 of the following year 2. Admission to an acute care institution (Facility Type Code = 1) 3. Discharge with diagnosis group of interest (i.e., one of the diagnosis groups that account for about 80% of in-hospital deaths, after excluding patients receiving palliative care) 4. Age at admission between 29 days and 120 years 5. Sex recorded as male or female 6. Length of stay of up to 365 consecutive days 7. Admission category is elective or emergent/urgent (Admission Category Code = U or L) Exclusion criteria: 1. Cadavers or stillborns (Discharge Disposition Code = 08 or 09) 2. Self sign-outs or did not return from a pass (Discharge Disposition Code = 06 or 12) 3. Records with brain death as most responsible diagnosis code 4. Records with most responsible diagnosis (MRDx) of palliative care (ICD-10- CA: Z51.5). For Quebec data: records where Z51.5 coded as MRDx, or cancer (C00 C97) coded as MRDx and Z51.5 coded in any secondary diagnosis field Expected deaths, or number of deaths that would have occurred in a hospital or region had the mortality of these patients been the same as the mortality of similar patients across the country, based on the reference year ( ). DENOMINATOR CALCULATION The HSMR logistic regression model is fitted with age, sex, length-of-stay (LOS) group, admission category, diagnosis group, co morbidity group and transfers as independent variables and is based on data from all acute hospitals in Canada (excluding Quebec). Coefficients derived from a logistic regression model are used to calculate the probability of inhospital death. The expected number of deaths for a hospital, corporation or region is based on the sum of the probabilities of inhospital death for eligible discharges from that organization. DAD, HMDB (CIHI) Inclusion criteria: 1. Discharge between April 1 of a given year and March 31 of the following year 2. Admission to an acute care institution (Facility Type Code = 1) 3. Discharge with diagnosis group of interest (i.e., one of the diagnosis groups that account for about 80% of in-hospital deaths, after excluding patients receiving palliative care) 4. Age at admission between 29 days and 120 years 5. Sex recorded as male or female 6. Length of stay of up to 365 consecutive days 2018/19 H-SAA Technical Specifications Page 37

38 7. Admission category is elective or emergent/urgent (Admission Category Code = U or L) Exclusion criteria: 1. Cadavers or stillborns (Discharge Disposition Code = 08 or 09) 2. Self sign-outs or did not return from a pass (Discharge Disposition Code = 06 or 12) 3. Records with brain death as most responsible diagnosis code 4. Records with most responsible diagnosis (MRDx) of palliative care (ICD-10- CA: Z51.5). For Quebec data: records where Z51.5 coded as MRDx, or cancer (C00 C97) coded as MRDx and Z51.5 coded in any secondary diagnosis field GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released E.g. Be as specific as possible..data are released annually in mid- May LEVELS OF COMPARABILITY Levels of geography for comparison Results are available on a quarterly (Q1 and Q2 in February, Q3 in May and Q4 in September) and annual (in September, together with Q4 reports) basis. Results are available for hospitals or hospital corporations (where applicable) and Local Health Integration Networks (LHINs). TRENDING Years available for trending FY till present ADDITIONAL INFORMATION LIMITATIONS Specific limitations COMMENTS Additional information regarding the calculation, interpretation, data source, etc. Currently no information has been provided. The reference year for HSMR calculations is To allow for comparisons over time, the coefficients derived from the model using the reference year are used to determine expected deaths for all reported years. While HSMR adjusts for a number of factors affecting the risk of in-hospital mortality, it does not control for every factor. Therefore, HSMR results are most useful in tracking trends over time. The following covariates are used in risk adjustment: 2018/19 H-SAA Technical Specifications Page 38

39 For each HSMR diagnosis group, the HSMR logistic regression models are fitted with age, sex, length-of-stay (LOS) group, admission category (urgent and elective), comorbidity (Charlson Index Score) group and transfers as independent variables. More information about HSMR calculation can be found here ( Changes to the HSMR methodology, implemented in February 2015, include the following: 1. HSMR results are calculated with an updated baseline using data. The previous baseline was calculated using data. 2. The statistical test of significance is based on comparing results with the national average (as opposed to 100). 1. Hospital Deaths (HSMR). REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, 2. Canadian Institute for Health Information. HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada. Ottawa, Ont.: CIHI, Jarman, B., A. Bottle and P. Aylin. Monitoring Changes in Hospital Standardised Mortality Ratios. BMJ 330 (2005): p Breslow, N. E. and N. E. Day. Statistical Methods in Cancer Research: Volume II The Design and Analysis of Cohort Studies. Lyon, France: International Agency for Research on Cancer, Quan, H., V. Sundararajan, P. Halfon, A. Fong, B. Burnand, J. C. Luthi, L. D. Saunders, C. A. Beck, T. E. Feasby and W. A. Ghali. Coding Algorithms for Defining Comorbidities in ICD-9-CM and ICD-10 Administrative Data. Medical Care 43, 11 (2005): pp RESPONSIBILITY FOR REPORTING CIHI DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) /19 H-SAA Technical Specifications Page 39

40 INDICATOR NAME RATE OF VENTILATOR-ASSOCIATED PNEUMONIA INDICATOR DESCRIPTION Detailed description of indicator INDICATOR CLASSIFICATION Pneumonia occurring in patients requiring mechanical ventilation, intermittently or continuously, through a tracheostomy or endotracheal tube for more than 48 hours Explanatory CALCULATION Total number of VAP cases age 18 and older that have required at least 48 hours of mechanical ventilation during the reporting period NUMERATOR Critical Care Information System (CCIS), Ontario Ministry of Health and Long- Term Care (MOHLTC) Includes: 1. All publicly funded hospitals 2. ICU beds 3. Patients diagnosed with VAP and being treated with antibiotics for VAP CALCULATION Excludes: 1. Patients age 17 and younger Total number of ventilator days for Intensive Care Unit (ICU) patients age 18 and older during the reporting period DENOMINATOR Critical Care Information System (CCIS), Ontario Ministry of Health and Long- Term Care (MOHLTC) Includes: 1. All publicly funded hospitals 2. ICU beds Excludes: 1. Patients age 17 and younger GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released E.g. Be as specific as possible..data are Data are available each quarter for the previous quarter s data 2018/19 H-SAA Technical Specifications Page 40

41 released annually in mid- May LEVELS OF COMPARABILITY Levels of geography for comparison Data are available at provincial, LHIN and hospital levels TRENDING Years available for trending LIMITATIONS Specific limitations Data are available for the previous quarter as of April 2009 Data are self-reported by hospital. No individual patient data are available; therefore this indicator cannot be broken down by socio-demographic characteristics. ADDITIONAL INFORMATION COMMENTS Additional information regarding the calculation, interpretation, data source, etc. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, Trending and comparisons are most valid by hospital type (e.g. small, large community, acute teaching, chronic care and rehab and mental health). This is in order to make limited adjustment for patient case mix. Patient Safety Website RESPONSBILITY FOR REPORTING Health Service Providers DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) /19 H-SAA Technical Specifications Page 41

42 INDICATOR NAME PROGRAM SPECIFIC INDICATOR NAME(S) How the indicator is named by specific programs Detailed description of indicator INDICATOR CLASSIFICATION CENTRAL LINE INFECTION RATE Central Line-Associated Primary Bloodstream Infection (CLI) Rate Number of intensive care unit (ICU) patients with new central line bloodstream infection (BSI)(CLI) per 1,000 central line days Explanatory CALCULATION Total number of laboratory confirmed BSI developing in patients age 18 and older in the ICU after 48 hours of placement of a central line NUMERATOR DENOMINATOR GEOGRAPHY & TIMING CALCULATION TIMING/FREQUENCY OF RELEASE How often, and when, are data being released E.g. Be as specific as possible..data are released annually in mid- May LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending Critical Care Information System (CCIS), Ministry of Health and Long-Term Care (MOHLTC) Includes: 1. Patients in the ICU 2. Patients age 18 and older Total number of central line days for patients age 18 and older in the ICU with a central line in place CCIS, MOHLTC Includes: 1. Patients in the ICU 2. Patients age 18 and older Data are available quarterly Data are collected at hospital institution level; can be aggregated up to Local Health Integration Network (LHIN) and provincial levels. Initial reporting started April 30, 2009 and included cumulative data for the three-month period January 01 to March 31, /19 H-SAA Technical Specifications Page 42

43 LIMITATIONS Specific limitations Currently, no information has been provided ADDITIONAL INFORMATION COMMENTS Additional information regarding the calculation, interpretation, data source, etc. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, RESPONSIBILITY FOR REPORTING O Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep. Aug ; 51(RR-10): Pittet D, Tarara D, Wemze; RP, Nosocomial bloodstream infection in critically ill patient. Excess length of stay, extra cost, and attributable mortality. JAMA 1994; (20): 271: Health Service Providers DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) /19 H-SAA Technical Specifications Page 43

44 INDICATOR DESCRIPTION INDICATOR NAME Detailed description of indicator INDICATOR CLASSIFICATION RATE OF HOSPITAL ACQUIRED METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS BACTEREMIA The rate of MRSA bacteremia is a measure of the incidence of laboratory confirmed bloodstream MRSA infection per 1,000 patient days Explanatory CALCULATION The total number of new nosocomial (i.e. hospital acquired) MRSA bacteremia cases in the reporting period multiplied by 1,000 NUMERATOR Self Reporting Initiative (SRI), Ontario Ministry of Health and Long-Term Care (MOHLTC) Includes: 1. All publicly funded hospitals 2. Inpatient beds 3. Laboratory-confirmed MRSA bacteremia cases (i.e. confirmation through a single positive blood culture for MRSA) 4. New nosocomial cases associated with the reporting facility is where the infection was not present on admission (i.e., onset of symptoms > 72 hours after admission) or the infection was present at the time of admission but was related to a previous admission to the same facility within the last 72 hrs. CALCULATION Excludes: 1. Long-term care beds The total number of patient days spent in-hospital in a reporting period DENOMINATOR GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released E.g. Be as specific as possible..data are Self Reporting Initiative (SRI), Ontario Ministry of Health and Long-Term Care (MOHLTC) Includes: 1. All publicly funded hospitals 2. Inpatient beds Excludes: 1. Long-term care beds Data are available each quarter for the previous quarter s data 2018/19 H-SAA Technical Specifications Page 44

45 released annually in mid- May LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending Data are available at provincial, LHIN and hospital levels Data are available for the previous quarter as of December 2008 Data are self-reported by hospital. LIMITATIONS Specific limitations No individual patient data are available; therefore indicator cannot be broken down by socio-demographic characteristics. ADDITIONAL INFORMATION COMMENTS Additional information regarding the calculation, interpretation, data source, etc. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, RESPONSIBILITY FOR REPORTING Trending and comparisons are most valid by hospital type (e.g. small, large community, acute teaching, chronic care and rehab and mental health). This is in order to make limited adjustment for patient case mix. Patient Safety Website Health Service Providers DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) /19 H-SAA Technical Specifications Page 45

46 INDICATOR NAME INDICATOR DESCRIPTION Detailed description of indicator INDICATOR CLASSIFICATION PERCENT OF PRIORITY 2, 3, AND 4 CASES COMPLETED WITHIN ACCESS TARGETS FOR CARDIAC BY-PASS SURGERY Descriptions of priority levels can be found in the link within the Reference section. Explanatory Step 1: Count the total number of cases completed for the reporting period by urgency category (Priority 2, 3 and 4). Please refer to the inclusion/exclusion criteria listed below. Step 2: Of the total count in step 1, count the number of cases where wait times are less than or equal to the provincial access target. Do this for all of the three urgency categories (Priority 2, 3, and 4). Step 3: The weighted percent of case completed within Priority 2, 3 and 4 access targets = sum of the counts by Urgency in step 2 divided by the sum of the counts by Priority in step 1 x 100 to get the percentage. CALCULATION Sample calculation: INDICATOR CCN Cardiac Registry. All Wait List Entries, off-listed as Procedure Started with procedure dates within date range submitted by hospitals to the CCN Cardiac Registry. Only isolated CABG surgery cases are included in the calculation. CABG surgery cases done in conjunction with other cardiac surgery procedures (i.e., valve surgery) are excluded. Cases with missing priority levels are excluded from the wait time calculation. Dates during which time a procedure is unable to take place for patient related and/or clinical reasons (Dates Affecting Readiness to Treat [DARTs]) are excluded from the wait time calculation. 2018/19 H-SAA Technical Specifications Page 46

47 GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released E.g. Be as specific as possible..data are released annually in mid-may LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending CCN has provided the MOHLTC with historical data on this indicator quarterly for FYs 2013/14 and 2014/15 to allow analysis of historical trends. LIMITATIONS Specific limitations ADDITIONAL INFORMATION COMMENTS Additional information regarding the calculation, interpretation, data source, etc. All hospitals performing CABG surgery in Ontario submit their wait time data to the Cardiac Care Network (CCN) Cardiac Registry and are included in the wait time calculation. Calculated percent of cases completed within access targets is based only on the number of cases entered in the system on data cut date scheduled on the 3rd business day after month end. CCN applies rigorous compliance, data quality and resubmission processes to check on completeness, validity and accuracy. For any questions, please contact Garth Oakes, Senior Lead Knowledge Translation and Privacy, CCN As part of CCN s on-going data quality improvement effort, accuracy is one of the key areas monitored and assessed on a regular basis along with other data quality dimensions. CCN provides monthly missing data reports to assist hospital data entry staff to ensure the completeness of data at the facility level. Data are reviewed at each month end by CCN staff to assess data quality. For questions regarding data quality, please contact Garth Oakes, Senior Lead Knowledge Translation and Privacy, CCN (goakes@ccn.on.ca). REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, RESPONSBILITY FOR REPORTING Cardiac Care Network of Ontario 2018/19 H-SAA Technical Specifications Page 47

48 DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) /19 H-SAA Technical Specifications Page 48

49 INDICATOR NAME INDICATOR DESCRIPTION Detailed description of indicator INDICATOR CLASSIFICATION PERCENT OF PRIORITY 2, 3, AND 4 CASES COMPLETED WITHIN ACCESS TARGETS FOR CANCER SURGERY Descriptions of priority levels can be found in the link within the Reference section. Explanatory Step 1: Count the total number of cases completed for the reporting period by priority level (Priority 2, 3 and 4). Please refer to the inclusion/exclusion criteria listed below. Step 2: Of the total count in step 1, count the number of cases where wait times are less than or equal to the provincial targets. Do this for all of the three priority levels (Priority 2, 3, and 4). Step 3: The weighted percent of cases completed within Priority 2, 3 and 4 access targets = sum of the counts by Priority in step 2 divided by the sum of the counts by Priority in step 1 x 100 to get the percentage. Sample calculation: CALCULATION INDICATOR Cancer Care Ontario (ATC, 2015). Access to Care has implemented a robust data quality and compliance framework to assess data quality under four key dimensions: timeliness, validity, reliability and usability. The complete framework is available in the Wait Time Conditions of Funding and further information is available upon request at: ATCsupport@cancercare.on.ca. Wait Time is calculated based on closed cases submitted by hospitals through the WTIS. 1. All closed wait list entries with procedure dates within date range. 2. Must be 18 and older on the day the procedure was completed. 3. Procedures no longer required are excluded from wait time calculation. 4. Includes treatment for cancer procedures only. Procedures classified as NA are currently included. Diagnostic, palliative and reconstructive cancer 2018/19 H-SAA Technical Specifications Page 49

50 procedures are excluded. Procedures on skin - carcinoma, skin-melanoma, and lymphomas are also excluded. 5. Procedures assigned as priority level 1 are excluded from wait time calculation. Cases with missing priority levels are also excluded. 6. Wait list entries identified by hospitals as data entry errors are also excluded. 7. If unavailable days fall outside the decision to treat date up to procedure date, unavailable days are not deducted from patients wait days. These are considered data entry errors. GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released E.g. Be as specific as possible..data are released annually in mid-may LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending The calculated percent of cases completed within priority target can be compared with the historical trend published in the Government of Ontario wait time s website. All inclusions/exclusions criteria used are similar. Also, historical wait times trend for low volume hospitals/lhins will show as NV (no or low volume) instead of a calculated percent of cases completed within priority target. LIMITATIONS Specific limitations ADDITIONAL INFORMATION COMMENTS Additional information regarding the calculation, interpretation, data source, etc. Hospitals submitting wait time data voluntarily (not required to report) are included in wait time calculation. Calculated percent of cases completed within priority target is based only on the cases entered in the system. Logically, hospitals not reporting cases promptly are excluded at the time of data extraction. Volumes submitted by hospitals are checked monthly for completeness. Hospital volume is compared against the expected monthly average. Outliers are validated with hospitals if the wait days are not accurate. As part of ATC s on-going data quality and compliance processes with hospitals, accuracy is one of the key areas that have been monitored closely over time and assessed on a regular basis along with other data quality dimensions. ATC monitors data quality with hospitals on a weekly basis and works closely with 2018/19 H-SAA Technical Specifications Page 50

51 hospitals WTIS coordinators to ensure data quality indicators and thresholds are met. If hospitals have challenges meeting data quality thresholds they may be excluded from wait time reporting calculations as well as public reporting. In these circumstances hospital, LHIN and/or ministry leadership is engaged to ensure hospital data quality is enhanced to become reportable as soon as possible. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, RESPONSBILITY FOR REPORTING Cancer Care Ontario DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) /19 H-SAA Technical Specifications Page 51

52 INDICATOR DESCRIPTION INDICATOR NAME Detailed description of indicator INDICATOR CLASSIFICATION PERCENT OF PRIORITY 2, 3 AND 4 CASES COMPLETED WITHIN ACCESS TARGETS FOR CATARACT SURGERY Descriptions of priority levels can be found in the link within the Reference section. Explanatory Step 1: Count the total number of cases completed for the reporting period by priority level (Priority 2, 3 and 4). Please refer to the inclusion/exclusion criteria listed below. Step 2: Of the total count in step 1, count the number of cases where wait times are less than or equal to the provincial targets. Do this for all of the three priority levels (Priority 2, 3, and 4). Step 3: The weighted percent of cases completed within Priority 2, 3 and 4 access targets = sum of the counts by Priority in step 2 divided by the sum of the counts by Priority in step 1 x 100 to get the percentage. CALCULATION Sample calculation: INDICATOR WTIS, ATC, Cancer Care Ontario. Access to Care has implemented a robust data quality and compliance framework to assess data quality under four key dimensions: timeliness, validity, reliability and usability. The complete framework is available in the Wait Time Conditions of Funding and further information is available upon request at: ATCsupport@cancercare.on.ca. All closed Wait List Entries with procedure dates within date range submitted by hospitals through the Wait Time Information System. Patient age greater than equals to 18 years old on the day the procedure was completed. Procedures No Longer required (or cancelled cases) are excluded from wait time calculation. 2018/19 H-SAA Technical Specifications Page 52