Runnymede Balanced Scorecard

Transcription

1 Strategic Direction Operational Excellence Growth Relationships Indicator Classification Runnymede Balanced Scorecard Performance Indicator Current Annual Rate of Clostridium Difficile Infection Hand Hygiene Compliance 90.0% 90.0% 91% 87.51% 3 ALC Rate 7.2%* 5.7% 7.0% 10.1% 4 New stage 2 to 4 Pressure Ulcer 1.5%* 1.4% 1.6% 2.0% 5 Falls 3.8* 3.9% 3.9% 11.5% 6 Medication Reconcilliation on Admission 100% 100% 100% n/a 7 Medication Reconcilliation on Discharge 100% 100% 95% n/a 8 Patient Satisfaction - Overall Quality of Care Rating 89.2% 80.4% 82.4% 82.4% 9 Family/Visitor Satisfaction - Overall Quality of Care Rating 95.6% 87.0% 93.1% 91.0% 10 Percentage of Unresolved Patient Complaints 0% 0% 0% n/a 11 Number of Critical Patient Incidents n/a 12 Lost Time Due To Injury Turnover Rate 4.01% 2.96% 9.2% 9.2% 14 Sick Time Rate 2.04% 2.62% 7.26% 7.26% 15 Percentage of IT Projects Completed on Budget 100% 66% 100% n/a 16 Electronic Medical Record (EMR) Implementation Readiness 10% 10% 100% n/a 17 RUGs Weighted Patient Days (RWPD) 61,483 40,639 87,047 n/a 18 Number of Annual ED Transfers n/a 19 Percentage of Non-MOHLTC Revenue 15.47% 14.9% 15.0% 14.4% 20 Total Margin 5.38% 5.38% 0.00% 4.50% 21 Current Ratio Number of LTLD patients admitted from SJHC /yr n/a 23 Average Length of Stay SJHC LTLD Rehab Patients days 24 Number of External Committee Appointments n/a 25 Number of Board Committee Appointments n/a 26 Annual Student Satisfaction Scores 66% N/A 75% n/a 27 Annual Number of Student Days ,989 n/a 28 Measure of Website Traffic (sessions) 37, ,791 39,976 n/a 29 Percentage of Corporate Departmental Processes Transitioned to Electronic 0% 0% 100% n/a 30 February 29, 2016 Current Q2 2015/16 Page Red Not achieving target by more than 10% Yellow Green * ^ Missing target by 10% or less Meeting or exceeding target Indicator values reflect most up-to-date data available Significant Corrections submitted to CIHI, results pending Value is based on a preliminary estimate. Indicator Classification MOHLTC requirement Quality Improvement Plan requirement RHC Strategic Plan requirement

2 Annual Rate of Clostridium Difficile Infection Operational Excellence Number of patients newly diagnosed with hospital-acquired Clostridium difficile Infection (CDI), divided by the number of patient days in that period, multiplied by 1,000. Clostridium difficile (also C. difficile or C. diff) is a common bacterium that is found in the environment and occurs naturally in some people. When C. difficile damages the bowel and causes diarrhea, it is known as Clostridium difficile-associated Disease (CDAD). CDI sometimes occurs when antibiotics are prescribed. Antibiotics work by killing off bacteria both bad and good bacteria. When good bacteria are killed, C.difficile can grow and release toxins that can damage the bowel and may cause diarrhea. In severe cases, surgery may be needed, and in extreme cases C. difficile may cause death. C. difficile is the most common cause of infectious diarrhea in hospitals and/or long-term care homes. Data Source: Surveillance data (Line listing of C. Difficile cases) Indicator Owner: Infection Control Practitioner Reporting Body: Accreditation Canada, Health Quality Ontario, MOHLTC Reporting Timeline: Calendar Year 0.4 Infection Prevention & Control (IPAC) Clostridium Difficile Associated Diseases CDI can spread when individuals come into contact with objects contaminated with the C. difficile bacteria such as toilets or bedpans used by a patient with the disease. Proper and frequent hand hygiene and thorough room cleaning are two ways to minimize the risk of spread Out of Quality Improvement Plan : 0.09/1000 Patient Days (Calendar Year) 2013 ( Jan - Dec) provincial average = Source: MOHLTC CDI Rate Current (Jan - Dec 2015/16) (Jan - Sept 2015/16) Two cases of hospital-aquired Clostridium difficile Infection (CDI) were witnessed for the months of October and December. No transmission between patients was observed. Eighty percent of all clinical staff to be educated on core competencies-education Module (Chain of transmission, Risk Assessment and Additional Precautions). Due Date Current Status Dec-15 APL-IPAC Sep-15 Completed Incorporates IPAC competencies into employee performance evaluations. Oct-15 APL-IPAC Jun-15 Completed CDI Rate Lead Date Initiated IPAC team to independently audit CDI room cleaning practices and report monthly to housekeeping manager. Dec-15 APL-IPAC Sep-15 Completed IPAC team to independently audit cleaning of commodes and report monthly. Dec-15 APL-IPAC Sep-15 In Progress - 2 -

3 Hand Hygiene Compliance Operational Excellence The number of times that hand hygiene was performed before initial patient contact divided by the number of observed hand hygiene indications before initial patient contact multiplied by 100. The single most common way of transferring health care-associated infections (HAIs) in health care settings is on the hands of health care providers. Health care providers move from patient to patient and room to room while providing care and working in the patient environment. This movement provides many opportunities for the transmission of organisms on hands that can cause infections. Proper hand hygiene will protect patients and providers and will reduce the spread of infections and the associated treatment costs, reduce hospital lengths of stay and readmissions, reduce wait times, and prevent deaths (MOHLTC 2011). Data Source: Internal Hand Hygiene Compliance Data (Observational Audit Sessions) Indicator Owner: Infection Control Practitioner Reporting Body: MOHLTC, Health Quality Ontario 100% 95% Hand Hygiene Compliance 90% : 91% (January - December 2014) 2014/2015 provincial average 87.51%. Source: MOHLTC Hand Hygiene Compliance Current (Jan - Dec 2015/16) (Jan - Sept 2015/16) Jan - Dec % 90% 91% Opportunities for improvement Hand Hygiene Compliance 85% 80% 75% 70% 65% 60% Performance is better than benchmark and the provincial average. There is ongoing education of staff regarding the importance of hand hygiene practices. 55% Out of 50% Calendar Year Incorporate Infection Prevention and Control (IPAC) competencies (including hand hygiene) into employee performance evaluations. Continue audit of hand hygiene practices with on the spot feedback and report monthly. Oct-15 APL-IPAC Jun-15 Completed Dec-15 APL-IPAC Sep-15 Completed Implement volunteer support to educate visitors on the importance of hand hygiene. Dec-15 APL-IPAC Oct-15 On Hold Eighty percent of all clinical staff to be educated on core competencies-education Module (Hand Hygiene) Dec-15 APL-IPAC Sep-15 Completed - 3 -

4 Indicator Alternate Level of Care Rate- Inpatient Days Operational Excellence ALC Rate (Inpatient Days) = Total number of ALC days in a given time period divided by total number of inpatient days in the same time period (Data available from Cancer Care Ontario (CCO) 2 months after quarter end). Data Source: CCO Lead Manager, Allied Health & Pharmacy Reporting Body: EAC, MAC, Quality Committee, Health Quality Ontario Significance - ALC avoidance has been identified as a strategic priority for our organization, and is part of our Quality Improvement Plan, with a target for the ALC rate of 6.9%. The ALC rate indicator represents an accurate count of total ALC days and total patient days for both open and closed cases in a given month, and therefore provides an accurate picture of ALC performance that can be tracked over time. 15.0% 13.0% ALC Rate TC LHIN ALC Rate 11.0% 9.0% Quality Improvement Plan : 7.0% (TC LHIN average for CCC hospitals): 12.2% 7.0% 5.0% ALC Rate ALC Rate Current (Q1 2015/16) 7.2% 5.7% Runnymede's ALC rate for Q2 2015/2016 increased from the previous quarter, as did the TC LHIN ALC rate, which reflects systemic pressures. For this quarter, our rate was worse than our target but outperformed the TC LHIN's average for CCC hospitals. 7.0% 3.0% 1.0% Q Q Q Q Q Q Q Q Q Participate in the TC LHIN task force on ALC Avoidance. Actions Review and update discharge policy in alignment with Toronto Central Local Health Integration Network (TC LHIN) Task Force recommendations. Streamlined and defined referral to Resource Matching Referral (RM&R) application. Mar-16 Chief Planning and Communications Officer Jun-15 In Progress Aug-15 Manager, Pharmacy & Allied Health Jan-15 Completed Mar-16 Chief Planning and Communications Officer Sep-15 In Progress - 4 -

5 New stage 2 to 4 Pressure Ulcer Domain Safety Q2 2015/16 (Jul-Sept 2015) Percentage of patients who had a newly occurring pressure ulcer at stages 2 to 4. Numerator - Patients who had a pressure ulcer at stages 2 to 4 on their target assessment and no pressure ulcer at stages 2 to 4 on their prior assessment. Denominator - Patients with valid assessments, excluding those with Stage 2-4 ulcers on prior assessment. Data Source: Clinical Lead: Reporting Body: Reporting Timeline: CIHI APL Nursing Health Quality Ontario, MAC Quality Committee Quarterly Pressure ulcers occur most commonly in the elderly, which is the fastest-growing segment of the population in healthcare. As a result, the number of patients at risk for developing pressure ulcers is expected to increase dramatically in the coming decades. Given the tremendous burden that pressure ulcers place on the healthcare system (pain, associated risk for serious infection, and increased health care utilization), there is a substantial need for improved prevention methods. Despite the growing emphasis placed on pressure ulcer prevention, pressure ulcers continue to be the most common preventable hospital-acquired condition. 4% 3% 2% Has a New Stage 2 to 4 Pressure Ulcer Current (Q2 2015/16) (Q1 2015/16) (QIP) 1.5% Indicates Unadjusted Rate 1.4% 1.6% performance target 1% Runnymede - Unadjusted Runnymede continues to outperform the target. Runnymede will continue to implement the appropriate skin and wound protocols for high risk patients as well as re-establishing and consulting with SWAT team when appropriate. 0% Re-educate nursing staff on the Skin and Wound protocol and wound prevention strategies. Explore development of a visual reminder for nursing staff to promote timely repositioning of patients. Actions Due Date Apr-16 Lead Advanced Practice Leader (APL) (Nursing) Incorporate bed rounds to identify mitigation strategies and goals. Apr-16 Interprofessional Team Apr-16 Clinical Educators Date Initiated Jun-15 Jun-15 Sep-15 Current Status In Progress In Progress In Progress - 5 -

6 (QIP) Has Fallen (includes only the patients with LOS greater than 90 days) Safety Q2 2015/16 (Jul-Sept 2015) Percent of patients who fell in the last 30 days of their MDS assessment period. Data Source: Clinical Lead: CIHI PPL-PT Numerator - Patients who had a fall in the last 30 days recorded on their target assessment. Reporting Body: Health Quality Ontario, MAC, Quality Denominator - Patients with valid assessments Committee While falls are relatively common for all ages, the likelihood increases with age. The impact of a fall is most severe among those older than age 65 and account for over 85 per cent of all injury-related hospitalizations in Has Fallen this age group. However, many falls can be prevented, and preventive interventions have great potential to 14% reduce the rate and degree of injury from a fall. The goal of rehabilitation is to encourage the fulfillment of personal goals, increase strength and stamina to avoid falls but the path to achieving mobility goals may put patients at an increased risk of falls. 12% 10% Current (Q2 2015/16) 3.8% 3.9% 3.9% Indicates Unadjusted Rate (Q1 2015/16) (QIP) This quarter Runnymede meets the Quality Improvement Plan target and remains substantially below benchmark. In total, five patients had falls during their MDS observation period which is a slight improvement over last quarter. 8% 6% 4% 2% 0% Runnymede - Unadjusted Fall Prevention Program policy and procedure going through approval process Actions Implement Fall Prevention Program changes recommended by the Fall Prevention Program Committee May-15 Clinical Practice Lead Allied Health Jul-14 In Progress Apr-15 Manager Pharmacy and Allied Health Apr-14 In Progress - 6 -

7 Medication Reconciliation at Admission Operational Excellence Medications prescribed at admission (or readmission after a transfer to acute care of greater than 24 hours) are reconciled with the patient's medications regimen before admission to Runnymede. Medication Reconciliation at Admission, a comprehensive review of patients' medication regimens at the point of admission, ensures patients safely transition into our facility.medications prescribed at the prior facility are verified, then patients, their families and or their community pharmacists are consulted, to determine any additional medication patients may have been taking at home. Data Source: Manual Indicator Owner: Manager, Pharmacy & Allied Health Reporting Body: Internal Medication Reconciliation at Admission 100% Runnymede 90% Quality Improvement Plan : 100% 80% N/A % of Medication Reconciliations on Admission Current 100% 100% 100% performance goal 70% 60% Medication Reconciliations continued to be completed for all patients admitted (or readmitted) in Q3. 50% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 2013/ / /16 Q3-7 -

8 Medication Reconciliation at Discharge Operational Excellence Medications prescribed at discharge from Runnymede are reconciled with the patients' medication regimens prior to admission to Runnymede. Medication Reconciliation at Discharge, a comprehensive review of patients' medication regimens at the time of discharge, ensures patients safely transition out of our facility. This process identifies discrepancies between patients' medication regimens prior to admission and the regimen prescribed at discharge. The discrepancies are summarized on a Best Possible Medication Discharge Plan (BPMDP) form, which is given to the patients/substitute Decision Makers to be shared with their primary care provider and community pharmacy, to provide clear information about any changes made to their medication regimen while at Runnymede. Data Source: Indicator Owner: Reporting Body: Reporting Timeline: 100% Manual Manager, Pharmacy & Allied Health Internal Quarterly Medication Reconciliation at Discharge Runnymede 90% Quality Improvemen Plan : 95% 80% N/A 70% % of Medication Reconciliations on Admission Current 100% 100% 95% performance goal 60% Medication Reconciliations continued to be completed for all patients discharged in Q3. 50% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 2015/ / /16-8 -

9 Patient Satisfaction - Quality of Care Rating Operational Excellence FY 2015/16 National Research Corporation Canada (NRCC): Patient Satisfaction - "Overall quality of care/services rating" The Ontario Hospital Association worked closely with NRCC to establish questions that would most appropriately measure patient satisfaction. The overall quality of care rating is based on several domains which have been corelated with quality of care. These domains are: Long Stay Resident Experience medical care & treatment, autonomy, dignity, staff, food, living environment and activities. Data Source: National Research Corporation Canada, Annual Patient Satisfaction Indicator Owner: Chief Planning and Communications Officer Reporting Body: Internal Reporting Timeline: Annual Patient Satisfaction - Quality of Care Rating 100% 95% 90% Quallity Improvement Plan : 82.4% 82.4%. Source: National Research Corporation Canada 85% 80% 75% Runnymede Patient Satisfaction - Quality of Care Rating Current (FY 2015/16) (FY 2014/15) 89.2% 80.4% 82.4% "Overall quality of care/services" rating has out performed previous period and target. CEO participates in OHA CCC Council and has input on NRCC questionnaires. 70% 65% Out of 60% 55% 50% 2013/ / /2016 Present survey results to Executive Team, Operations Committee, Patient Family Council, Strategic Planning Committee and Board of Directors. Engage with patients and families through different channels to obtain feedback on patient experience and opportunities for improvement. Develop and implement improvement strategy and action plan based on 2015/2016 satisfaction survey results. Conduct annual Patient Satisfaction Survey Chief Planning and Dec-15 Sep-15 Completed Communications Officer Mar-16 Mar-16 Mar-16 Chief Planning and Communications Officer Chief Planning and Communications Officer Chief Planning and Communications Officer Apr-15 Nov-15 Dec-15 Completed In progress In progress - 9 -

10 Family/Visitor Satisfaction - Quality of Care Rating Operational Excellence FY 2015/16 National Research Corporation Canada (NRCC): Family/Visitor Satisfaction - "Overall quality of care/services rating" The Ontario Hospital Association worked closely with NRCC to establish questions that would most appropriately measure family/visitor satisfaction. The overall quality of care rating is based on several domains which have been corelated with quality of care. These domains are: global quality, care and services, activities, communication, living environment and assistance with living. Data Source: National Research Corporation Canada, Annual Patient Satisfaction Indicator Owner: Chief Planning and Communications Officer Reporting Body: Internal Reporting Timeline: Annual Family/Visitor Satisfaction - Quality of Care Rating 100% 95% Runnymede Performance 90% 85% : 93.1% 80% 75% 91.0%. Source: National Research Corporation Canada Current (FY 2015/16) (FY 2014/15) Family Satisfaction % 87.0% 93.1% Quality of Care Rating "Overall quality of care/services" rating has out performed previous period and target. CEO participates in OHA CCC Council and has input on NRCC questionnaires. Out of 70% 65% 60% 55% 50% 2013/ / /2015 Present survey results to Executive Team, Operations Committee, Patient Family Council, Strategic Planning Committee and Board of Directors. Engage with patients and families through different channels to obtain feedback on patient experience and opportunities for improvement. Develop and implement improvement strategy and action plan based on 2015/2016 satisfaction survey results. Conduct annual Patient Satisfaction Survey Dec-15 Mar-16 Mar-16 Mar-16 Chief Planning and Communications Officer Chief Planning and Communications Officer Chief Planning and Communications Officer Chief Planning and Communications Officer Sep-15 Apr-15 Nov-15 Dec-15 Completed Completed In progress In progress

11 Percentage of Unresolved Patient Complaints Operational Excellence Percentage of reported patient and/or family member concerns that have not been resolved. Runnymede is committed to patient centred care and continuous quality improvement. This indicator ensures patient concerns are monitored and addressed. Data Source: Indicator Owner: Reporting Body: Reporting Timeline: Patient Relations Records Chief Planning and Communications Officer Internal Quarterly Percentage of Unresolved Patient Complaints 100% 90% Out of 80% : 0% 70% 60% N/A 50% 40% Current 30% Percentage of Unresolved Patient Complaints 0% 0% 0% 20% 10% has been met. No further action required. 0% Runnymede 2014/ /

12 Number of Critical Patient Incidents Operational Excellence Number of Critical Patient Incidents per quarter, where a critical incident is any unintended event that occurs when a patient receives treatment in the hospital, that results in death or serious disability, injury or harm to the patient, and does not result primarily from the patient's underlying medical condition from a known risk inherent in providing treatment. Data Source: Incident Reporting System Indicator Owner: Chief Planning and Communications Officer Reporting Body: Internal Measures the safety of our patient care services. Any result greater than zero represents significant harm experienced by a patient or patients and significant risk of liability for the hospital. 5 Number of Critical Patient Incidents 4 : 0 3 N/A 2 Number of Critical Patient Incidents Current Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2014/ /2016 Due Date Lead Date Initiated Current Status Implementation of approved QCIPA review recommendations. Dec-15 Chief Planning and Communications Officer Jun-14 Completed

13 Lost Time Due to Injury Operational Excellence Lost Time Due to Injury is the average number of allowed Workplace and Safery Insurance Board (WSIB) lost time injury claims per 195,000 employee hours worked. The Lost Time Due to Injury indicator can be used to determine the effectiveness of the organization's efforts on accident and injury prevention compared to other hospitals within the same rate group. Data Source: Occupational Health Indicator Owner: Interim Director, Human Resources Reporting Body: Workplace Safety & Insurance Board Reporting Timeline: Annual A high or increasing Lost Time Due to Injury Rate may indicate an improvement is needed in workplace safetyrelated initiatives and/or increased education on safe work processes. 3 Lost Time Due To Injuries Outof 2.5 : Annual target = The benchmark rate of 1.66 is the Lost Time Injuries (LTI) rate established by the WSIB for Hospitals (Group 853). The LTI rate is determined as the number of LTIs per 100 FTEs (195,000 hours worked). LTI Rate 1.5 LTI Rate Current has been met. Case disability management initiative has reduced the lost time due to injury. The hospital will continue to closely monitor this indicator to prevent a spike similar to Q Runnymede Runnymede 2014/ /2016 Case disability management program implemented. Ongoing program. Sep-15 Interim Director, Human Resources Jul-15 In progress

14 Turnover Rate Operational Excellence The turnover rate is defined as the number of permanent employees that left the employment of Runnymede Healthcare Centre (i.e. voluntary or involuntary). As a means of ensuring statistical significance for the data a fiscal year time period will be used to measure the turnover rate. Data Source: Human Resources Indicator Owner: Interim Director, Human Resources Reporting Body: OHA, Price Waterhouse Reporting Timeline: Annual A high turnover rate may indicate employee dissatisfaction and the need to determine the root causes for the high turnover rate and implementing or changing initiatives and strategies to retain staff. Turnover Rate Out of 16 : Annual target = 9.20% 14 The benchmark will be the 25% percentile turnover rate for Hospitals as set out in the Saratoga Human Resources ing Survey conducted by the Ontario Hospital Association and Price Waterhouse. Turnover Rate Current 4.01% 2.96% 9.2% Turnover Rate (%) Continue to outperform the target, however a slight increase is noted due to the nursing redesign. 2 0 Runnymede Runnymede 2014/ /2016 Due Date Lead Date Initiated Current Status

15 Sick Time Rate Operational Excellence Q3 2015/2016 Average number of sick leave days per full-time employee across the Organization and source: OHA HR Survey 2013 (10th percentile - best quartile) Data Source: Indicator Owner: Reporting Body: Reporting Timeline: Human Resources Interim Director, Human Resources OHA Quarterly Sick Time Rate 8.00% 7.00% 6.00% : 7.26% Ontario Hospital Association: Hospital HR - Sick Leave Survey % 5.00% 4.00% Sick Time Rate Current 3.00% Average Paid Sick Days Per Employee 2.04% 2.62% 7.26% performance goal 2.00% The metric outperforming the benchmark. Initiatives introduced in the first quarter continue to be reinforced and have continued to drive this indicator lower contributing to a continued marked decrease in sick time. Of note is the Ontario Hospital Association (OHA) Absence Survey , (last reported data) reports that the overall average number of sick days per eligible employee across Ontario hospitals has slightly increase from 9.41 to 9.47 days. The organization remains far below this average. 1.00% 0.00% Q1 Q2 Q3 Q4 15/16 Implement mandatory proof of absence surrounding statutory holidays. Ongoing Interim Director, Human Resources Apr-15 Ongoing The next phase of the Initiative will focus on the sick absences with durations of less than 6 days Interim Director, Human Mar-16 and greater than 3 days. Resources Jan-16 Pending Approval of Attendance Managment Policy. Apr-16 Interim Director, Human Resources Jun-15 In progress

16 Percentage of IT Projects Completed on Budget Operational Excellence The number of approved applications and information technology (IT) projects completed on budget. Project management methodologies and procurement guidelines are applied to ensure expenditures fall within the approved financial budget. Data Source: Workplan Status Report Indicator Owner: Director, Information Services and Facilities Management Reporting Body: Internal Percentage of Internal IT Projects Completed on Budget : 100% 100% N/A Percentage of Internal IT Project Completed on Budget Current 100% 66% 100% 80% 60% 40% 20% RHC RHC Performance Storage Area Network (SAN) Refresh - Completed on budget. Firewall Replacement - Completed on budget. 0% Out of Due Date Lead Date Initiated Current Status Uninterruptible Power Supply (UPS) RFP Completed and implementation in progress. Complete electrical infrastructure modifications and commission the new UPS Mar-16 Director, Information Services and Facilities Management Sep-15 In progress Document Management - RFP Process is nearing completion with preferred vendor contract negotiation in progress. Pilot "Go-Live" due date is estimated at 4 months post contract signing. Jul-16 Director, Information Services and Facilities Management Jul-15 In progress Wireless infrastructure upgrade will complete in March. Mar-16 Director, Information Services and Facilities Management Sep-16 In progress

17 Electronic Medical Record (EMR) Implementation Readiness Growth Data Source: Project Reporting Data Percentage of completed (Phase 1) milestones (compared with planned milestones for the same period) required for Runnymede to commence the implementation of an EMR. Indicator Owner: TBD Phase 1 - Will include site preparation tasks of data quality analysis, clinical process reviews and a public RFP for consultative support in developing a business case outlining the technological, procedural and governance gaps/requirements for Runnymede's future EMR. Reporting Body: Reporting Timeline: Internal Quarterly Implement technology including an electronic patient record to support information access and security. It has been demonsrated that technology creates more patient - centric services, while reducing the cost of delivering secure, high-quality care. : 100% 100% 80% EMR Implementation Readiness N/A Electronic Medical Record (EMR) Implementation Readiness Current 10% 10% 100% Opportunities for Improvement 60% 40% Out of In line with the written direction to pause Health Information Services renewals from the Ministry of Health and Long Term Care (MOHLTC), the hospital is in the process of preparing to request an exemption from this directive to proceed with the business case development. ADT data analysis and cleanup with vendor continues with patches being implemented in next ADT software release. Due Date Admit Discharge Transfer (ADT) Data analysis and clean up to be completed - dependent on vendor provide software update. Jul-16 20% RHC Performance, 10% 0% 2015/ / / /2019 Lead Date Initiated Current Status Director, Information Services and Facilities Management Sep-15 In progress Development of a revised milestone plan. Consultation/guidance regarding strategic planning requires input from VP of Information Services. TBD* Director, Information Services and Facilities Management Nov-15 On hold Formation of a Electronic Medical Record (EMR) task force. Consultation/guidance regarding strategic planning requires input from VP of Information Services. TBD* Director, Information Services and Facilities Management Nov-15 On hold Confirmation from MOHLTC of directive to proceed with business case development. Consultation/guidance regarding strategic planning requires input from VP of Information Services. TBD* TBD Aug-14 On hold Staff computer training and re-enforcement through a daily computer use requirement. In anticipation of an EMR, will re-introduce a basic computer training solution for staff requiring assistance. July Director, Information Services and Facilities Management Nov-15 In progress * Pending Ministry approval to proceed with EMR

18 RUGs Weighted Patient Days Growth Patient days (the number of patients per day) are grouped into Resource Utilization Groups (RUG) which are assigned a weight to create a RUG Weighted Patient Day (RWPD). RWPDs are calculated as the number of days associated with a RUG III group multiplied by the group specific case mix index (CMI) value [RWPD = CMI x Patient Days]. The RWPD is a reflection of both patient acuity and volumes. A higher RWPD value indicates higher patient acuity and/or higher patient volumes. Runnymede's ability to provide increased RWPD demonstrates the hospital's participation as a system partner in caring for medically complex patients and ensuring that patients requiring complex continuing care have access to the services they require. : Annual: 87,047 RWPD. Source H-SAA. (Quarterly target: 21,762 RWPD) N/A RUGs Weighted Patient Days Current (Q2 2015/15) The estimated Q3 RWPD is 20,801. The Q3 occupancy rate remains high at 98% and the estimated CMI is There has been an increase in the CMI from last quarter based on an in-depth review and improvement startegies put in place. The overall RUGS weighted pateint days is below target as it is based on achieving 100% occupancy and 95 beds at a CMI of 1.12 and 105 beds at a CMI of % occupancy with appropriate patient population. Annual 20,801 40,639 87,047 Opportunities for improvement Due Date Mar-16 Data Source: CIHI Indicator Owner: Chief Planning and Communications Officer Reporting Body: MOHLTC, TC LHIN Forecast Actual Forecast Actual Actual Lead Date Initiated Current Status Chief Planning and Communications Officer RUGs Weighted Patient Days Forecast Actual Forecast Actual Forecast Actual Forecast Actual Oct-15 Actual Forecast Actual Forecast Actual Forecsat Actual Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 13/14 14/15 15/16 In Progress Conduct a CMI analysis. Dec-15 MDS Coordinators Oct-15 Completed

19 Number of Annual ED Transfers Growth The cumulative number of patients transferred to the emergency department of an acute care hospital during the fiscal year per 1000 patient days. The patient may have or may not have been admitted to acute care. Data Source: Health Information Services Indicator Owner: Chief Nursing Executive Reporting Body: Internal Reducing the number of patients transferred to acute care improves the patient experience by reducing the number of transitions for a patient and reduces the overall burden on the health care system. Where possible, Runnymede should seek to expand clinicians' scope of practice to reduce the need for transfer to acute care. A higher number of transfers to the emergency department may signify a higher patient acuity level Number of Annual ED Transfers Quality Improvement Plan : 2.41 Admissions per 1000 Patient Days N/A Q4 Q4 Q4 Out of Q3 Number of Annual ED Transfers Current Opportunities for improvement Q2 Q3 Q3 Q3 Q2 Q2 Q2 2 1 Q1 Q1 Q1 Q / / / /16 Nursing to identify clinical advanced procedures that contribute to ED transfers. Feb-16 Director of Nursing Sep-15 In Progress

20 Percentage of Non-MOHLTC Revenue Growth Q3 FY 2015/16 Total revenue earned from other sources (all revenue not derived from MOHLTC) divided by Total Revenue (all sources). Growth of MOHLTC revenue is limited. Revenue has not kept pace with inflation and other operating expense pressures. Hospitals must seek out alternative ways to maximize revenue. Data Source: Financial Statements Indicator Owner: Interim Chief Financial Officer Reporting Body: MOHLTC Percentage of Non-MOHLTC Revenue 25.0% 20.0% : 15.0% 14.3% Source: HIT Tool (YE data 2014/15 YE Chronic/Rehab hospitals) 15.0% 10.0% Out of Runnymede Percentage of Non- MOHLTC Revenue Current 15.47% 14.99% 15.0% 5.0% Performance metric exceeds the target and benchmark. The Percentage of Non-MOHLTC revenue indicator will reflect a significant decrease below the annual target in Q4 given the incremental MOHLTC revenue that will be recognized during Q4. Non-MOHLTC Revenue is expected to continue as in prior quarters. 0.0% 2013/ / /

21 Total Margin Growth Q3 FY 2015/16 Percent by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expenses, excluding the impact of facility amortization in a given year. Financial effectiveness and viability reflects the hospital's ability to operate within funding/revenues earned. This indicates that there is operational efficiency, ensuring that there are sufficient resources required to purchase necessary equipment and provide patient care. Data Source: HIT Tool (MOHLTC) Indicator Owner: Interim Chief Financial Officer Reporting Body: MOHLTC Total Margin 15% 10% : 0% 1.8% Source: HIT Tool (2014/15 YE Chronic/Rehab hospitals) 5% Runnymede Total Margin Current 5.38% 5.38% 0% Total Margin exceeds the benchmark and the target. The forecasted year-end total margin indicator will reflect a significant increase compared to Q2 & Q3 results given the incremental one-time and base MOH revenue that will be recognized in Q4. 0% Out of -5% FY 2013/2014 FY 2014/2015 FY 2015/2016 Implementation of electronic management reports that meet the needs of the department heads for decision making purposes: - a new statistical report to be determined based upon management input Operationalize the Case Costing Data for improvements and efficiencies. Aug-16 Aug-16 Interim, Chief Financial Officer Interim, Chief Financial Officer Jun-14 Jun-14 In Progress In Progress

22 Current Ratio Growth Q3 FY 2015/16 Current Assets Current Liabilities, The number of times a hospital's short term obligations can be paid using the hospital's short term assets. The hospital's ability to pay current liabilities including staff salaries and wages which comprise of approximately 75% of expenses allows management to focus on operational excellence/quality care for our patients and community. Data Source: HIT Tool (MOHLTC) Indicator Owner: Interim Chief Financial Officer Reporting Body: MOHLTC 5 Current Ratio Runnymede : Source: Hit Tool (2014/2015 YE Chronic/Rehab hospitals) Current Ratio Current Performance for Q3 FY 2015/16 is positive and exceeds target and benchmark Out of FY 2013 FY 2014 FY

23 Number of LTLD Rehab Patients Admitted from SJHC Growth The number of patients admitted to Runnymede's 3 West Low Tolerance Long Duration Rehabilitation (LTLD Rehab) Program from St. Joseph's Health Centre (SJHC). This includes inpatients as well as patients referred from SJHC Ambulatory clinics (outpatients). Data Source: Manual count Indicator Owner: Chief Planning and Communications Officer Reporting Body: SJHC, Internal SJHC has the highest percentage of Alternate Level of Care (ALC) patients in the Toronto Central LHIN. This collaboration will help to alleviate system pressures by freeing up acute care beds at SJHC and transitioning patients to a more appropriate setting at Runnymede. The LTLD Program will ensure patients that require a slower pace less intensive rehab will receive the right care at the right place. On May 14, 2012, 34 new LTLD Rehab beds were opened in collaboration with SJHC which resulted in the hiring of over 60 new professionals. : 180 patients annually (45 patients quarterly) n/a Number of LTLD Patients Admitted from SJHC 13/14 Annual Performance 14/15 Annual Performance Annual Number of LTLD Patients Admitted from SJHC Current Performance has exceeded target. No further action required Quarterly 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2013/ / /

24 Average Length of Stay of SJHC LTLD Rehab Patients Growth Patients admitted to Runnymede's Low Tolerance Long Duration Rehabilitation (LTLD Rehab) Program from St. Joseph's Health Centre (SJHC) effective May 14, This includes inpatients as well as patients referred from SJHC Ambulatory clinics (outpatients). 1 patient requiring LTLD Rehab was admitted to Runnymede from SJHC during the period of April 1 - May 13, This patient was not included in the data for purposes of monitoring metrics outlined in the agreement between Runnymede and SJHC. Average Length of Stay (ALOS) SJHC LTLD Rehab Patients = Sum of the Length of stay of separated patients (days)/number of patients separated year to date. Separations = patients who are discharged from Runnymede to an alternate level of care (e.g. home, acute care, LTC, etc.) and patients who have deceased. Data Source: Indicator Owner: Reporting Body: Reporting Timeline: 100 Manual Count Chief Planning and Communications Officer SJHC, Internal Quarterly Average Length of Stay of LTLD Rehab Patients (Quarterly) A higher average length of stay will result in a lower patient turnover rate and hence will decrease the number of patients who can access the LTLD Rehab Program. An average length of stay less than 69 days would warrant a review of the complexity of patients accessing the program. Out of : Annual average = 69 days Days 50 Runnymede Performance 3-6 months. Source: GTA Rehab Network 40 ALOS LTLD Rehab Patients Current days The shorter length of stay facilitates the admission of a greater volume of patients. No further analysis required / / /2016 Due Date Lead Date Initiated Current Status

25 Number of External Committee Appointments Relationships Number of staff that have joined Provincial, TC LHIN or Health Sector committees/ task forces/working groups since April 1, Promote Runnymede as a CCC sector leader through representation on Provincial, TC LHIN and Health Sector committee/ task forces/working groups. Ties in with Runnymede's vision of leading the way in complex continuing care. Data Source: Manual Count Indicator Owner: Chief Planning and Communications Officer Reporting Body: Internal Number of New External Committee Appointments : Annual = 2 N/A Q4 Number of External Committee Appointments Current Q2 Q3 Q3 1 achieved no further analylsis required / /2016 Out of Continue to encourage staff to participate in external committees. Mar-16 Chief Planning and Communications Officer Nov-15 In progress Q1 Q1-25 -

26 Number of Board Committee Appointments Relationships Number of external Board of Directors appointments of Runnymede executives. Board appoinments support continuous leadership development and provides increased recognition for both the individual and Runnymede Healthcare Centre. Data Source: Manual Count Indicator Owner: Chief Planning and Communications Officer Reporting Body: Number of Board Committee Appointments 6 5 : Annual = 3 4 N/A 3 Number of Board Committee Appointments Current Q1 & Q2 Q3 has been met. No further action required /

27 Annual Student Satisfaction Scores Relationships Percentage of students (undergraduate nursing, allied health, pharmacy and activation) who answered "likely" or "very likely" (or at least 4 out of 5 on numerical scale) to the question: "How likely are you to recommend Runnymede to other students?" Measures student satisfaction for the year with respect to our ability to provide a positive learning experience. Also students are a source for future hires. Data Source: Student Satisfaction Survey Indicator Owner: Chief Nursing Executive & Chief Privacy Officer Reporting Body: Internal Student Satisfaction 100% 90% : 75% n/a Current Percentage of students who responded favourably 80% 70% 60% 50% 40% 30% Out of Student Satisfaction 66% N/A 75% Opportunities for improvement 20% Student surveys have indicated opportunities for improvement. Nursing redesign and lay off notices are some of the factors attributable to engagement. 10% 0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2013/ / /16 Communicate with Operations Committee members the new process of facilitating graduate student placements and reporting of data. Feb-16 Chief Nursing Executive & Chief Privacy Officer Sep-15 In Progress

28 Number of Annual Student Days Relationships Number of students' days in attendance at Runnymede as part of an academic program.this includes clinical and non clinical students, but does not include volunteers. Providing student placements and experiences builds our relationships with academic centres. Data Source: Education Records Indicator Owner: Chief Nursing Executive & Chief Privacy Officer Reporting Body: Internal Number of Annual Student Days : Annual target = Q4 Q4 n/a Number of Annual Student Days Current (Q1-) (Q1-Q2 2015/16) Annual ,989 Opportunities for improvement Runnymede's future strategy identifies a shift away from undergraduate student intake. As a result, student days for undergraduate and college prepared Nursing students is anticipated to decline Q4 Q3 Q2 Q1 Q3 Q2 Q3 Q2 Q1 Q4 Q3 Q2 Q1 Out of Q3 Q2 Q1 2011/ / / / /

29 Measure of Website Traffic Relationships The units of measurement are "sessions", where the Runnymede Healthcare Centre website is accessed and explored. Data Source: Runnymede Website Indicator Owner: Chief Planning and Communications Officer Reporting Body: Internal The Runnymede website is used to provide information and resources to external stakeholders and assist them in their decision making related to careers, volunteering, patient care and/or charitable donations. The website enhances Runnymede's profile within the community and with other healthcare organizations and can be used to facilitate an interactive relationship between us and our stakeholders by providing an opportunity for visitors to submit comments/feedback. 100,000 90,000 Measure of Website Traffic 80,000 : Annual = 50,833 70,000 60,000 50,000 N/A 40,000 Number of Visits per Quarter Current Performance is on track to meet target. 37,258 25,791 Annual 50,833 30,000 20,000 10,000 0 Q1 Q2 Q3 2015/2016 Out of Due Date Lead Date Initiated Current Status

30 The number of corporate departmental processes transitioned to electronic completed compared to the annual plan. A paperless strategy will reduce solid waste generation and support the hospital's "green" approach. The focus for Phase 1 is to transition corporate departmental processes to electronic. Subsequent phases will focus on patient care processes. : 100% Percentage of Corporate Departmental Processes Transitioned to Electronic Operational Excellence Data Source: Workplan Status Report Indicator Owner: Director, Information Services and Reporting Body: Internal 100% Percentage of Corporate Departmental Processes Transitioned to Electronic N/A 80% Current 60% RHC Performance Percentage of Corporate Departmental Processes Transitioned to Electronic 0% 0% 100% Opportunities for improvement 40% 20% Document Management - Request for proposal (RFP) process almost completed with final contract negotiations occuring with the preferred vendor. Electronic Boardroom - Awaiting finalized doc management solution - as potential for leveraging technology for boardroom. Other potential solutions are being investigated for submission to senior leadership as alternate considerations for a boardroom solution. Due Date Document Management - RFP Process is nearing completion with preferred vendor contract negotiation in progress. Pilot "Go-Live" due date is estimated at 4 months post contract signing. Electronic Boardroom - Clarification will occur post Doc Management contract signing. Based on available solutions, a requirements document will be prepared and confirmation with senior management on project scope obtained. In cooperation with corporate departments, identify opportunities for paperless technology solutions and document within a baseline plan for comparison moving forwards. Jul-16 Lead Director, Information Services & Facilities Management Director, Information Services & Facilities Management Director, Information Services & Facilities Management Date Initiated Sep-14 Current Status In progress In progress In progress Implement Facilities hand held devices for mobile ticket response. May-16 Manager, Facilities Oct-16 In progress Aug-16 Jul-16 0% Jun-14 Mar-16 Out of