Runnymede Balanced Scorecard

Transcription

1 Strategic Direction Operational Excellence Growth Relationships Indicator Classification Balanced Scorecard Performance Indicator Current Annual Rate of Clostridium Difficile Infection Hand Hygiene Compliance 90.0% 90.0% 91% 87.51% 3 ALC Rate 4.3%* 6.8% 6.9% 10.1% 4 Has new Pressure Ulcer 0.2%* 0.4% 1.0% 2.0% 5 Falls 9.3%* 6.3% 3.6% 11.5% 6 Urinary Tract Infections 4.0%* 3.9% 2.8% 3.5% 7 Pain 2.9%* 2.1% 4.3% 7.1% 8 Worsening Pain 3.2%* 4.8% 7.5% 8.0% 9 Medication Reconcilliation on Admission 100% 100% 100% n/a 10 Patient Satisfaction - Overall Quality of Care Rating 89.2% 80.4% 82.4% 82.4% 11 Family/Visitor Satisfaction - Overall Quality of Care Rating 95.6% 87.0% 93.1% 91.0% 12 % of Unresolved Patient Complaints 0% 0% 0% n/a 13 # of Critical Patient Incidents n/a 14 Lost Time Due To Injury Turnover Rate 5.29% 5.77% 9.2% 9.2% 16 Sick Time Rate 3.36% n/a 7.26% 7.26% 17 % of IT Projects Completed on Budget 100% 60% 100% n/a 18 Electronic Medical Record (EMR) Implementation Readiness 0% n/a 100% n/a 19 RUGs Weighted Patient Days (RWPD) 20,492 83,234 87,047 n/a 20 # of Annual ED Transfers n/a 21 % of Non-MOHLTC Revenue 15.6% 16.4% 15.0% 14.4% 22 Total Margin 0.23% 5.39% 0.00% 4.50% 23 Current Ratio # of LTLD patients admitted from SJHC /yr n/a 25 Average Length of Stay SJHC LTLD Rehab Patients days 26 # of External Committee Appointments n/a 27 # of Board Committee Appointments n/a 28 Student Satisfaction Scores 100% 82% 75% n/a 29 # of Student Days 408 1,945 1,989 n/a 30 Measure of Website Traffic (sessions) 13,135 48,413 39,976 n/a 31 % of Corporate Departmental Processes Transitioned to Electronic 0% 60% 100% n/a 32 November 11, 2015 Current Q4 2014/15 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 (CDAC). 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: Infection Prevention & Control (IPAC) 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 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 : 0.09/1000 Patient Days (Calendar Year) 2013 (Jan - Dec) provincial average = Source: MOHLTC CDI Rate Current (January-June 2015/16) (January-March 2015) continues to out perform provincial average CDI Rate Due Date Lead Date Initiated Current Status Incorporates IPAC competencies into employee performance evaluations. Oct-15 APL-IPAC Jun-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 : 91% (January - December 2014) 2014/2015 provincial average 87.51%. Source: MOHLTC Hand Hygiene Compliance Current (Jan-June 2015) (Jan-March 2015) Jan - Dec % 90% 91% Opportunities for improvement Continue reinforcement regarding the importance of good hand hygiene of frontline staff. Efforts are underway to analyze data rigorously to identify action plans. Hand Hygiene Compliance 90% 85% 80% 75% 70% 65% 60% 55% Out of 50% Calendar Year Incorporates Infection Control and Prevention competencies (including hand hygiene) into employee performance evaluations. Continue audit of hand hygiene practices and report monthly. Oct-15 APL-IPAC Jun-15 In Progress Oct-15 APL-IPAC Jun-15 Completed - 3 -

4 Indicator ALC 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 Mgr, 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% Quality Improvement Plan : 6.9% (TC LHIN average for CCC hospitals): 12.1% 9.0% 7.0% Current (Q3 2014/15) 5.0% ALC Rate ALC Rate 4.3% 6.8% 6.9% 3.0% 's ALC rate for Q4 2014/2015 decreased from the previous quarter. For this quarter, our rate continues to outperform both our target and the TC LHIN's average for CCC hospitals indicating successful implementation ALC avoidance strategies by the patient care team. 1.0% Q Q Q Q Q Q Q Q Presentation by ALC patient care coordinator on a complex successful discharge. Actions Jun-15 Manager, Pharmacy & Allied Health Jun-15 Completed - 4 -

5 New stage 2 to 4 Pressure Ulcer Domain Safety Q4 2014/15 (Jan-Mar 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 completed 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. Pressure ulcers place a burden on patients with increased pain and reduced of quality of life in addition to increasing costs and resource utilization to the healthcare institution and system. Therefore, there is a need for improved pressure ulcer prevention methods. Despite the growing emphasis placed on pressure ulcer prevention, pressure ulcers continue to be the most common preventable hospital-acquired condition. 5% Has a New Stage 2 to 4 Pressure Ulcer 4% Quality Improvement Plan : 1.0% (TC LHIN average - Q4 2014/15): 1.8% 3% - Unadjusted Current (Q3 2014/15) Unadjusted 2% Percentage 0.2% 0.4% 1.0% continues to outperform the benchmark. will continue to assess patients on admission and implement the appropriate skin and wound protocols for high risk patients. No new actions required. 1% 0% - Adjusted Actions - 5 -

6 Has Fallen Safety Q4 2014/15 (Jan-Mar 2015) Percent of patients who fell in the last 30 days of their MDS assessment period. Numerator - Patients who had a fall in the last 30 days recorded on their target assessment. Denominator - Patients with completed assessments 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 this age group. However, many falls can be prevented, and preventive interventions have great potential to 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. Data Source: CIHI Clinical Lead: PPL-PT Health Quality Ontario, MAC, Quality Reporting Body: Committee Has Fallen 14% 12% Quality Improvement Plan : 3.6% (TC LHIN average - Q4 2014/15): 12.4% Current (Q3 2014/15) Unadjusted Percentage 9.3% 6.3% 4.1% Opportunities for improvement underperforms in relation to the QIP target but outperforms the benchmark. The performance of 9.3% corresponds to six patients who fell during this reporting period. These falls occurred despite prevention and harm reduction strategies being in place. Five out of the six fallers scored high on the Cognitive Performance Scale (CPS). These patients may have perceptual or coordination difficulties and would not remember to utilize the assistance that is recommended. They can have poor insight into their abilities and therefore attempt activities that are outside of what they are capable of performing safely. 10% 8% 6% 4% 2% 0% - Unadjusted - Adjusted - Unadjusted Adjusted Actions Continue with semi-annual auditing of adherence to Fall Prevention Program Jun-15 Physiotherapist Apr-15 Complete Approval of Fall Prevention Program policy and procedure Feb-16 Clinical Practice Lead Allied Health Jul-14 In Progress - 6 -

7 Has Urinary Tract Infection (UTI) Other Clinical Issues Q4 2014/15 (Jan-Mar 2015) Percent of patients with a urinary tract infection during the 30 day observation period. Numerator - Patients with urinary tract infection on their target assessment. Denominator - Patients with completed assessments, excluding end-of-life patients Data Source: Clinical Lead: Reporting Body: CIHI APL Nursing MAC, Quality Committee, Health Quality Ontario Canadian Nosocomial Infection Surveillance Program (CNISP) definition: Criteria 1 - Patient has at least one of the following signs or symptoms with no other recognized cause: fever (>38C), urgency, frequency, dysuria or suprapubic tenderness; and positive urine culture Criteria 2 - Patient has at least two of the following signs or symptoms with no other recognized cause: fever (>38C), urgency, frequency, dysuria or suprapubic tenderness; and at least one of the following: - positive dipstick - physician diagnosis of a urinary tract infection - physician institutes appropriate therapy for a urinary tract infection Urinary Tract Infection (UTI) has long been considered the most common healthcare-associated infection (HAI), with the vast majority of these infections occurring after placement of the often unnecessary urinary catheter. Monitoring and reducing catheter use is key in preventing Catheter Associated Urinary Tract Infections (CAUTI). Reporting Timeline: 10% 9% 8% 7% 6% Quarterly Has UTI 5% 4% Quality Improvement Plan : 2.8% (TC LHIN average - Q4 2014/15): 3.5% 3% 2% 1% - Adjusted - Unadjusted Current (Q3 2014/15) Unadjusted 0% Unadjusted Percentage 4.0% 3.9% 4.0% Opportunities for improvement underperforms compared to the QIP target and the benchmark. Patients who triggered this indicator had a history of UTIs with causative factors which include urinary retention, and Foley catheter usage. will continue to reinforce education on prevention of Catheter Associated Urinary Tract infections (CAUTI). Two significant corrections have been submitted to CIHI to be in line with the CNISP definition. Actions Significant Corrections submitted and accepted, changes will be reflected in. Jun-15 MDS Coordinator Jun-15 Complete Implement communication of specified times for toileting and prompting to all clinical team members through documentation in Patient Care Plan (ICP-A) and bedside signage to ensure consistency of all clinical members. Jul-15 Clinical Educators May-15 Complete - 7 -

8 Has Pain Other Clinical Issues Q4 2014/15 (Jan-Mar 2015) Percent of patients with pain. Numerator - Patients with moderate pain at least daily or horrible/excruciating pain at any frequency documented on their target assessment. Denominator - Patients with completed assessments Pain is a signficant factor affecting quality of life. Patient centered concerns need to be addressed to effectively manage and/or correct pain. A collaborative interprofessional, multi-faceted approach is used to ease the suffering and improve the quality of life of those living with pain. Data Source: CIHI Clinical Lead: APL Nursing Health Quality Ontario, Quality Reporting Body: Committee, MAC Has Pain 20% 18% 16% Quality Improvement Plan : 4.3% (TC LHIN average - Q4 2014/15): 5.4% Current (Q3 2014/15) Unadjusted Percentage 2.9% 2.1% 1.7% continues to outperform the QIP target and the benchmark; however performance has declined compared to Q3 2014/15. Pain experienced by patients was related to their delining health status, complex medical diagnosis, and history of chronic pain. These patients had been placed on scheduled pain relief measures which resulted in improved pain control and management. 14% 12% 10% 8% 6% 4% 2% 0% - Unadjusted Adjusted Actions Implement RNAO's best practice guidelines on pain management, including non-pharmacological approaches. Educate all interprofessional team members on the revised interprofessional pain management policy May-15 Clinical Educators Apr-15 Complete Dec-15 Advanced Practice Lead (APL) Nursing Jul-15 In Progress Reassess the pain management of patients who are exhibiting signs or symptoms of pain. Aug-14 Patient Care Managers May-14 In Progress - 8 -

9 Has Worsened Pain Other Clinical Issues Q4 2014/15 (Jan-Mar 2015) Percent of patients whose pain worsened. Numerator - Patients with greater pain (higher Pain Scale score) on their target assessment compared with their prior assessment. Denominator - Patients with completed assessments whose pain symptoms could increase (did not have maximum Pain Scale score on prior assessment) Pain is a signficant factor affecting quality of life. Patient centered concerns need to be addressed to effectively manage and/or correct pain. A collaborative interprofessional, multi-faceted approach is used to ease the suffering and improve the quality of life of those living with pain. Data Source: CIHI Clinical Lead: APL Nursing Reporting Body: CIHI Has Worsened Pain 20% 18% Quality Improvement Plan : 7.5% (TC LHIN average - Q4 2014/15): 8% Current (Q3 2014/15) Unadjusted Percentage 3.2% 4.8% 4.3% outperforms both the QIP target and the benchmark and performance has improved since Q3 2014/15. Patients triggering this indicator had chronic and terminal diseases and included patients who were non-compliant with pain medications. Actions - Unadjusted - Adjusted Identify pain management strategies for worsened and uncontrolled pain during rounds. Oct-15 Clinical Educators Apr-15 In progress Implement standardized pain assessment using the "PQRST" approach. Jul-15 Clinical Educators Apr-15 Complete 16% 14% 12% 10% 8% 6% 4% 2% 0%

10 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. 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: Indicator Owner: Reporting Body: Reporting Timeline: Manual Manager, Pharmacy & Allied Health Internal Quarterly Medication Reconciliation at Admission 100% 90% : 100% 80% % of Medication Reconciliations on Admission Current ( 2014/15) 100% 100% 100% performance goal 70% 60% Q1 ended with a return to 100% of patients admitted having a Medication Reconciliation completed at Admission (or Readmission). 50% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 2013/ / /

11 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% : 82.4% 82.4%. Source: National Research Corporation Canada 85% 80% 75% 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 iimprovement strategy and action plan based on 2015/2016 satisfaction survey results. Conduct annual Patient Satisfaction Survey Chief Planning and Dec-15 Sep-15 In progress 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 In progress In progress

12 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% 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 iimprovement 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 In progress In progress In progress

13 Percentage of Unresolved Patient Complaints Operational Excellence Percentage of reported patient and/or family member concerns that have not been resolved. 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% Percentage of Unresolved Patient Complaints Current 0% 0% 0% 30% 20% 10% has been met. No further action required. 0% 2013/ /

14 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 recommendations. Dec-15 Chief Planning and Communications Officer Jun-14 In Progress

15 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: 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. Continue to monitor and look for further initiatives to reduce lost time due to injury / /2016 Development of case disability management program underway. Jun-15 Interm Director, Human Resources May-15 Completed

16 Turnover Rate Operational Excellence The turnover rate is defined as the number of permanent employees that left the employment of 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 5.29% 5.77% 9.2% Continue to out peform the target. No further action required. Turnover Rate (%) / /2016 Due Date Lead Date Initiated Current Status

17 Sick Time Rate Operational Excellence Q1 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: Human Resources Indicator Owner: Interim Director, Human Resources Reporting Body: OHA 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 3.36% N/A 7.26% performance goal 2.00% The metric is outperforming the benchmark. During the first quarter the organization introduced mandatory sick notes for all nursing staff absent on any day surrounding a statutory holiday. This has had an immediate impact on this indicator. Additionally, the organization has increased it s efforts in return to work protocols and increased surveillance in occupational health with the assistance of the central scheduling office. This greater coordination of efforts has had the desired affect. Of note is the Ontario Hosptial 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 The next phase of the Initiative will focus on the sick absences with durations of less than 6 days and greater than 3 days. Approval of Attendance Managment Policy. Interim Director, Human Resources Apr-15 Mar-16 Jan-16 Interim Director, Human Resources Interim Director, Human Resources Jan-16 Jun-15 Pending In progress Implement mandatory proof of absence surrounding a statutory holidays. Ongoing Ongoing

18 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 80% RHC Percentage of Internal IT Project Completed on Budget Current 100% 60% 100% 60% 40% RHC Performance Information Services Citrix infrastructure review completed on budget. 20% 0% Out of Due Date Lead Date Initiated Current Status Voic Host infrastructure to be installed and refresh project completed. Aug-15 Director, Information Services and Facilities Management Jul-15 Planned Information Services Security road map and review to be received and analysis completed Sep-15 Director, Information Services and Facilities Management Jun-15 In progress Case Costing 2014/15 submission to be finalized, submitted with greater than 95% accuracy rate. Oct-15 Director, Information Services and Facilities Management Jun-15 In progress Firewall upgrade - Hardware to be received and implementation planned with vendor. Nov-15 Director, Information Services and Facilities Management Sep-14 In progress

19 Electronic Medical Record (EMR) Implementation Readiness Growth Data Source: Percentage of completed (Phase 1) milestones (compared with planned milestones for the same period) required for to commence the implementation of an EMR. Indicator Owner: 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 's future EMR. 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% Reporting Body: Reporting Timeline: 100% 80% Project Reporting Data Director, Information Services and Facilities Maangement Internal Quarterly EMR Implementation Readiness N/A Electronic Medical Record (EMR) Implementation Readiness Current 0% n/a 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. 20% 0% 2015/ / / /2019 Confirmation from MOHLTC of directive to proceed with business case development. Due Date Dec-15 Lead Date Initiated Current Status Director, Information Services and Facilities Management Aug-14 In progress Admit Discharge Transfer (ADT) Data analysis and clean up to be completed. Mar-16 Director, Information Services and Facilities Management Sep-15 In progress Staff computer training and re-enforcement through a daily computer use requirement. Mar-16 Director, Information Services and Facilities Management Nov-15 In progress

20 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. '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. Data Source: CIHI Indicator Owner: Chief Planning and Communications Offcer Reporting Body: MOHLTC, TC LHIN RUGs Weighted Patient Days : Annual: 87,047 RWPD. Source H-SAA. (Quarterly target: 21,762 RWPD) N/A Forecast Forecast Forecast Forecast Forecast Actual Forecast Actual Forecast RUGs Weighted Patient Days Current Annual 20,492 83,234 87,047 Opportunities for improvement Actual Actual Actual Actual The Q1 RWPD continues to trend downwards with 17,759 patient days and a CMI of The trend of CMI going down can be attributed to the increase in LTLD patients. The occupancy rate for Q1 is 98%. The Q4 RWPD are 83,234. This 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 1.3. The Q4 CMI of 1.18 is the highest amonst peers in the TC LHIN and is the third highest in the province. The Q1 RWPD continues to be below target with 17,759 patient days (representing a 98% occupancy rate) and a CMI of Actual Actual Actual Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 13/14 14/15 15/16 100% occupancy with appropriate patient population. Due Date Mar-16 Lead Date Initiated Current Status Chief Planning and Communications Officer Oct-15 In Progress Conduct a CMI analysis. Dec-15 MDS Coordinators Oct-15 In Progress

21 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, 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 : 2.41 Admissions per 1000 Patient Days N/A Q4 Q4 Q4 Out of Number of Annual ED Transfers Current (Q4 2014/2015) The performance of this indicator is short of the target Opportunities for improvement Q3 Q2 Q3 Q3 Q2 Q2 1 Q1 Q1 Q1 Q / / / /16 Due Date Lead Date Initiated Current Status Review best practices and develop oral care policy in collaboration with Dental Centre. Jan-15 Chief Nursing Executive Sep-14 Complete Root cause analysis (Including review of all cases) to identify preventable ED transfers from Sep-15 Chief Nursing Executive Sep-15 Complete

22 Percentage of Non-MOHLTC Revenue Growth 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 Director, Finance Reporting Body: MOHLTC Percentage of Non-MOHLTC Revenue 25.0% 20.0% : 15.0% 14.4% Source: HIT Tool (YE data 2013/14 YE Chronic/Rehab hospitals) 15.0% 10.0% Out of Percentage of Non- MOHLTC Revenue Current 15.62% 16.40% 15.0% On track to meet annual target. 5.0% Performance indicator is on track to meet the target and benchmark. 0.0% 2012/ / / /

23 Total Margin Growth 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 Director, Finance Reporting Body: MOHLTC Total Margin 15% 10% : 0% 4.5% Source: HIT Tool (2013/14 YE Chronic/Rehab hospitals) 5% Total Margin Current 0.23% 5.39% 0% Total margin exceeds the benchmark and the target. This trend is expected to increase as the incremental MOHLTC revenue is recognized in the second half of the year. 0% Out of -5% FY 2012/2013 FY 2013/2014 FY 2014/2015 FY 2015/

24 Current Ratio Growth 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 and quality care for our patients and community. Data Source: HIT Tool (MOHLTC) Indicator Owner: Interim Director, Finance Reporting Body: MOHLTC 5 Current Ratio : Source: Hit Tool (2013/2014 YE Chronic/Rehab hospitals) Current Ratio Current The current ratio exceeds the. This trend is expected to continue for the balance of the fiscal year Out of FY 2012 FY 2013 FY 2014 FY

25 Number of LTLD Rehab Patients Admitted from SJHC Growth The number of patients admitted to '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 Oficer 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. 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 Current patients were admitted in Q1 of 2015/16 which is 14 more patients than target. There continues to be a high occupancy on the unit demonstrating a strong ongoing need and as the average length of stay decreases, the number of patients admitted increases Number of LTLD Patients Admitted 13/14 Annual Performance 14/15 Annual Performance Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 13/14 14/15 15/

26 Average Length of Stay of SJHC LTLD Rehab Patients Growth Patients admitted to '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 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 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 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 3-6 months. Source: GTA Rehab Network Days ALOS LTLD Rehab Patients Current days The cumulative ALOS for the 2014/15 fiscal year is 54 days. The shorter length of stay facilitates the admission of a greater volume of patients / / /2016 Due Date Lead Date Initiated Current Status

27 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 as a CCC sector leader through representation on Provincial, TC LHIN and Health Sector committee/ task forces/working groups. Ties in with '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 = N/A Number of External Committee Appointments Current Opportunities for Improvement Q2 Q3 Q / /2016 Out of Continue to encourage staff to participate in external committees. Mar-16 Chief Planning and Communications Officer Nov-15 In progress Q1 Q1-27 -

28 Number of Board Committee Appointments Relationships Number of external Board of Directors appointments of executives. Board appoinments support continuous leadership development and provides increased recognition for both the individual and Healthcare Centre. Data Source: Manual Count Indicator Owner: Chief Planning and Communications Officer Reporting Body: Number of Board Committee Appointments : Annual = 3 5 N/A 4 Number of Board Committee Appointments Current Opportunities for Improvement Q1 Currently 2 of the 3 executives sit on external boards. Continue to encourage and support external board appointments /

29 Annual Student Satisfaction Scores Relationships Percentage of students (undergraduate nursing and allied health) 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 to other 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 Reporting Body: Internal Student Satisfaction 100% 90% : 75% n/a Current (Q4 2014/2015) Percentage of students who responded favourably 80% 70% 60% 50% 40% 30% Out of Student Satisfaction 100% 82% 75% 20% Satisfaction results exceed the target. 10% 0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 2013/ / /

30 Number of Annual Student Days Relationships Number of students' days in attendance at 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 Reporting Body: Internal Number of Annual Student Days Out of : Annual target = Q4 Q4 n/a 2500 Current (FY 2014/15 ) Annual 2000 Number of Annual Student Days 408 1,945 1,989 Opportunities for improvement 1500 Q4 Q3 Q3 Q4 With the Nursing redesign program, there is a need for more graduate students. As a result, student days for undergraduate and college prepared Nursing students is anticipated to decline Q3 Q2 Q2 Q2 Q3 Q2 0 Q1 Q1 Q1 Q1 2011/ / / / /

31 Measure of Website Traffic Relationships The units of measurement are "sessions", where the Healthcare Centre website is accessed and explored. Data Source: Website Indicator Owner: Chief Planning and Communications Officer Reporting Body: Internal The 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 '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. 13,135 48,413 50,833 30,000 20,000 10,000 0 Q1 2015/2016 Out of Due Date Lead Date Initiated Current Status

32 The number of corporate departmental processes transitioned to electronic completed compared to the annual plan. Percentage of Corporate Departmental Processes Transitioned to Electronic Operational Excellence 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. Data Source: Workplan Status Report Indicator Owner: Director, Information Services and Facilities Management Reporting Body: Internal Percentage of Corporate Departmental Processes Transitioned to Electronic : 100% 100% 80% N/A Percentage of Corporate Departmental Processes Transitioned to Electronic Current 0% 60% 100% Opportunities for improvement 60% 40% 20% RHC Performance Two projects (Electronic Boardroom and Document Management) deferred but budgeted and planned for complettion in 2015/ % Out of Document Management - Project commencement and Request for Proposal (RFP) preparation planned for July Due Date Jul-15 Lead Director, Information Services & Facilities Management Date Initiated Sep-14 Current Status Planned Electronic Boardroom - Confirmation of project scope with senior administration. Planned for Q3. TBD Director, Information Services & Facilities Management Jun-14 Planned