Champlain Health System Performance and Accomplishments

Transcription

1 hamplain Health System Performance and Accomplishments Technical Report November 2015

2 Table of ontents Page Number(s) Section A Overview Status of All Indicators A1-A2 Section B Ministry LHIN Accountability Agreement (MLAA) Indicator Trends B1 Section Detailed Indicator Performance Report* 1-24 Timely Access to the are Needed Right are, Right Place High Quality, Safe and Effective are hamplain LHIN Organizational Health Health System Fiscal Management and Value Performance Indicator Refresh Schedule Section D Methodology D1-D2 Section E Acronyms E1 * Includes indicators with updated data this quarter

3 Section - Overview Status of All Indicators (Indicator page number in brackets) Indicator Domain Indicator Display Name 1.1 Time in ER for omplex Patients (hours) Timely Access to the are Needed urrent Performance Achieved Time in ER for Not Admitted Uncomplicated Patients (hours) Hip Replacement Wait Time Knee Replacement Wait Tme MRI Scan Wait Time T Scan Wait Time Wait for Home are (ommunity lients) (days) 1.8 Personal Support Visit within 5 Days of Application 1.9 Nursing Visit Within 5 Days of Application Adults With a Primary are Provider n/a 92.9 n/a 1.11 Timely (Same / Next Day) Access to a n/a n/a Primary are Provider 42.5 Right are, Right Place 2.1 Patients in Acute Hospital Beds Needing Other are (AL) AL Rate Repeat Mental Health ED visitors Repeat Substance Abuse ED visitors High Priority lients Receiving A are at Home Long Term are Placements for Highest 82.5 Priority lients Admission to LT Homes from ommunity Patients Designated AL Who Were 9.2 Discharged to Long Term are Homes AL days Attributable to Palliative are 2.1 Patients Hospitalization Rate for Ambulatory are Sensitive onditions (per 100,000) ER visits for conditions best managed elsewhere (per 1000) hamplain Health System Performance and Accomplishments: November 2015 A1

4 Indicator Domain Indicator Display Name Positive Healthcare Experience Indicators under development urrent Performance Achieved High Quality, Safe and Effective are 4.1 Readmissions for ertain hronic onditions 4.2 Early Elective Low-Risk Repeat -Sections 4.3 omplex are Hospital Patients with New Pressure Ulcers 4.4 Long Term are Residents with New Pressure Ulcers 4.5 Physician Visit Within 7 days of Discharge hamplain LHIN Operational Health Health System Fiscal Management and Value 4.6 Hospitalization Due to Falls Among Long- Term are Residents (per 1000) 4.7 Fall-Related Emergency Department Visit Rate Among Seniors (per 100,000) 4.8 Fall-Related Hospitalization Rate Among Seniors (per 100,000) 5.1 Status of LHIN Annual Business Plan Initiatives 5.2 LHIN Enterprise Risk Assessment n/a risks partially and fully mitigated 5.3 LHIN Operational Budget Variance + or LHIN Staff Turnover Twitter Followers hamplain LHIN YouTube Views LHIN Employee Satisfaction n/a 50 n/a 5.8 Website Traffic n/a 14,310 n/a 6.1 Hospital ost Efficiency n/a 3.01 n/a 6.2 A Home are ost Efficiency n/a n/a 6.3 Total Margin - Hospital n/a 6.4 Total Margin - ommunity are Access entre 6.5 Total Margin - ommunity Health entres 6.6 Total Margin - ommunity Support Services 6.7 Total Margin - Mental Health and Addictions Agencies n/a n/a n/a n/a n/a Note: Indicators in italic font are ones that have been adopted by the hamplain LHIN over and above those which the LHIN is accountable for under its performance agreement with the Province. These additional indicators provide an additional dimension of performance understanding. - Indicators with an indicator page number have updated data available this quarter in Section hamplain Health System Performance and Accomplishments: November 2015 A2

5 Reported 12-Aug-2015 Note: Data for 12-Aug-15 is the most recent quarter of data available. Historical results (found in columns 1 through 8) are provided for the previous eight quarters, where available, and are based on the new indicator technical specifications. The grayed out cells have not been calculated. hamplain Health System Performance and Accomplishments: November 2015 B1 Section B - Ministry LHIN Accountability Agreement (MLAA) Indicator Trends for hamplain No. MLAA Indicators LHIN (2015/16) Performance Indicators Home and ommunity Percentage of home care clients with complex needs who received their personal support visit within 5 days of the date that they were authorized for personal support services Percentage of home care clients with complex needs who received their nursing visit within 5 days of the date they were authorized for nursing services th Percentile Wait Time for A In-Home Services - Application from ommunity Setting to first A Service (excluding case management) System Integration and Access 4 90th percentile emergency department (ED) length of stay for complex patients th percentile emergency department (ED) length of stay for minor/uncomplicated patients Percent of priority 2, 3 and 4 cases completed within access target for MRI scans Percent of priority 2, 3 and 4 cases completed within access target for T scans Percent of priority 2, 3 and 4 cases completed within access target for hip replacement Percent of priority 2, 3 and 4 cases completed within access target for knee replacement Percentage of Alternate Level of are (AL) Days AL rate Health and Wellness of Ontarians - Mental Health 12 Repeat Unscheduled Emergency Visits within 30 Days for Mental Health onditions Repeat Unscheduled Emergency Visits within 30 Days for Substance Abuse onditions Sustainability and Quality 14 Readmission within 30 days for selected HIG conditions Notes (Refers to 12-Aug-15 data only) /16 data (Apr, May, Jun 2015) /15 Data (Jan, Feb, Mar 2015) /15 data (Oct, Nov, Dec 2014)

6 (Indicators with updated data this quarter) November 2015

7 TIMELY ASS TO THE ARE EDED MLAA 8.0 Baseline Rank - 11 Hours Lower Values are Better 1.1 Time in ER for omplex Patients Trend Baseline LHIN 9.7 Prov (8.0) 9.7 ES HP W T Hours Notes: 90th percentile: 90 out of 100 complex cases were completed in less time. Seasonal indicator, best performance expected in and. This indicator is new and includes the length of stay for both admitted and non-admitted complex patients. hamplain's performance is consistent with the provincial average but above the new provincial target of 8.0 hours. The wait time for an inpatient bed is the most significant driver of hamplain's performance on this indicator. Emergency departments continue with implementation of quality improvement initiatives to improve patient flow. The LHIN also continues with initiatives to reduce alternate level of care (AL) which will contribute to inpatient beds being available in a timely way. hamplain LHIN is participating in an initiative led by Access to are to identify hospitals that are the best performers on this indicator and to ensure their performance enabling practices are transferred. Over the longer term investments are being made in Health Links to help manage demand. Improvements in this metric are expected by the end of the fiscal year, but we are unlikely to achieve the target in this fiscal year. MLAA 4.0 Baseline Rank - 13 Hours Time in ER for Minor Uncomplicated Patients Prov (4.0) Lower Values are Better W ES T 4.4 HP Trend Baseline LHIN Hours Notes: 90th percentile: 90 out of 100 uncomplicated cases were completed in less time. Includes TAS IV and V who were not admitted. Seasonal indicator, best performance expected in and. The provincial target of 4 hours is new for this indicator. hamplain's performance of 4.5 hours is above the target and similar to the baseline. hamplain's emergency rooms continue to see increasing volumes of both complex and non-complex patients. Overall, volumes increased 1 over the same quarter last year. Emergency departments continue to focus on improvement strategies such as Rapid Assessment Zones, triage process improvements and additional staffing to address wait times for non-complex patients. Over the longer term investments are being made in Health Links to help manage demand. Incremental performance improvement is expected over of the remainder of the fiscal year, but it is unlikely to achieve the target in this fiscal year. hamplain Health System Performance and Accomplishments: November

8 MLAA 90.0 Baseline Rank Higher Values are Better Trend Baseline LHIN 1.3 Hip Replacement Wait Time Notes: Percent of cases completed within the following access targets: priority 2 (urgent) 42 days; priority 3 (semi-urgent) 84 days; priority 4 (elective) 182 days. The hamplain LHIN continues to peform above average. The development of centralised intake through our Regional Orthopedic Program, along with the addition of urgent and semi-urgent patients, has highlighted a variation in coding of urgency within in one of our hospitals, which has since been rectified. We expect to reach the provincial target within 3-6 months Prov (90.0) HP T ES W MLAA 90.0 Baseline Rank Higher Values are Better Trend Baseline LHIN 1.4 Knee Replacement Wait Time Notes: Percent of cases completed within the following access targets: priority 2 (urgent) 42 days; priority 3 (semi-urgent) 84 days; priority 4 (elective) 182 days. hamplain continues to perform well and is approaching targeted performance. The standardisation in coding of urgencies noted above will further improve our performance Prov (90.0) HP T W ES hamplain Health System Performance and Accomplishments: November

9 MLAA 1.5 MRI Scan Wait Time 90.0 Baseline Rank Higher Values are Better Trend Baseline LHIN Notes: Percent of cases completed within the following access targets: priority 2 (urgent) 2 days; priority 3 (semi-urgent) 2 to 10 days; priority 4 (elective) 28 days. Performance has declined as there continues to be capacity challenges because requests for scans exceeds the number of funded scans. Work continues on process improvements for a more effective way of directing and booking MRI requests. Hospitals continue to transfer patients from sites with long wait times to those with shorter wait times to mitigate patient waits, however, the difference between sites in wait times is declining. Efforts to reduce unnecessary exams are being evaluated, but are expected to have a small impact as these are not a significant issue. apacity considerations are: Overall, MRI efficiency continues to meet or exceed the provincial targets at all hamplain sites. A new MRI machine will be operational in the fall of This increases capacity by 40 hours per week, less than 3 of the overall LHIN capacity. A hospital has temporarily reduced the number of hours by 40 hours per week to upgrade a scanner. A large teaching hospital reduced the hours of service funded from its global budget by 40 hours per week to balance its budget. The LHIN continues to reinforce that SAA wait time targets need to be met. Due to capacity concerns, performance improvement is dependant on increased resource availability. We do not anticipate achieving the provincial target this fiscal year ES HP W T MLAA 90.0 Baseline Rank Higher Values are Better Trend Baseline LHIN 1.6 T Scan Wait Time Notes: Percent of cases completed within the following access targets: priority 2 (urgent) 2 days; priority 3 (semi-urgent) 2 to 10 days; priority 4 (elective) 28 days. Performance on T scan wait times continued to decline while a number of measures were implemented to improve efficiency and improve access to the services. There is a supply-demand imbalance. One large hospital has reduced their hours of service in order to balance its budget. The LHIN will ensure that the hospital does not fall below the Hospital Service Accountability Agreement (HSAA) targeted hours. The LHIN continues to have capacity challenges and the backlog continues to grow. The hospitals are transferring patients from sites with long wait times to those with shorter wait times to mitigate some of the access issues. Efficiency does not appear to be a problem in hamplain.due to capacity concerns, performance improvement is dependant on increased resource availability. We do not anticipate achieving the provincial target this fiscal year Prov (90.0) 7 7 ES T HP W hamplain Health System Performance and Accomplishments: November

10 MLAA 21.0 Baseline Rank - 14 Days Wait for Home are (ommunity lients) Prov (21.0) Lower Values are Better W ES T Trend Baseline LHIN HP Days Notes: 90th percentile: 90 out of 100 clients received service within less time. A data. In the most recent quarter, the A worked to provide services to a large number of clients who had been on the wait list. Only clients who receive a first visit within the reporting period are included in the metric. As a result, performance on this indicator has worsened temporarily but is expected to improve in the near future. It has been a priority for the LHIN and the hamplain A to improve intake processes to better meet this target. For example, the hamplain A will be introducing additional efficiency processes at intake, such as the introduction of the interrai-preliminary Screen to streamline clients to service, online self-serve tools to begin assessments prior to intake, and looking at various staffing profiles to maximize resources at intake. The hamplain A has an active sustainability plan and several programs to ensure that its average cost per client population group are in the top quartile of the province and that available funds are used effectively. urrent programs include clinic utilization, rationalization of equipment and supply catalogues, implementation of care pathways, and adjustments to service guidelines. It is anticipated that by the end of the 3rd quarter, the LHIN will be within 20 of the target. MLAA 95.0 Baseline Rank Personal Support Visits within 5 Days of Application Prov (95.0 Higher Values are Better ES 9 6 W T Trend Baseline LHIN HP Notes: is 95 of visits within 5 days. Excludes clients aged less than 18 years. See indicators on nursing visits and wait for home care. Performance in of 20 declined from the previous quarter. In the most recent quarter, the A worked to provide services to a large number of clients who had been on the wait list for personal support services. As a result, performance on this indicator has worsened temporarily. The hamplain LHIN and the hamplain ommunity are Access entre (A) are working on several initiatives to improve this indicator, including increasing the efficiency of the client intake process and providing additional resources to assess the care needs of patients. Effective September 2015 A has eliminated the waitlist for personal support services therefore this component will now be at zero. This should enable the hamplain LHIN to be in line with other LHINs by, The progress on the A's intake improvements and the waitlist management will continue to be monitored by the LHIN. hamplain Health System Performance and Accomplishments: November

11 MLAA 95.0 Baseline Rank Nursing Visits within 5 Days of Application Higher Values are Better Trend Baseline LHIN Notes: is 95 of visits within 5 days. Excludes clients aged less than 18 years. See indicators on personal support visits and wait for home care. Performance on this indicator is close to target and has been consistently over 90. The hamplain LHIN and the hamplain ommunity are Access entre (A) are working on several initiatives to improve this indicator, including increasing the efficiency of the client intake process and providing additional resources to assess the care needs of patients. It is expected that the LHIN will meet the target by the end of the fiscal year Prov (95.0 W ES T HP hamplain Health System Performance and Accomplishments: November

12 RIGHT ARE, RIGHT PLA MLAA 9.5 Baseline Rank Patients in Acute Hospital Beds Needing Other are (AL) Prov (9.5) Lower Values are Better Trend Baseline LHIN W T HP ES Notes: Based on patients who were discharged from acute care beds during specified period. Excludes patients still in hospital. In this quarter, performance was better than that provincial average, but still not achieving the target. Extremely high patient volumes in acute hospitals in the region made it difficult for the LHIN to maintain patient flow and to reduce Alternate Level of are days. Throughout this period the LHIN and senior hospital executives worked closely to address these volume issues. A multitude of initiatives are in place to improve flow of patients out of inpatient beds (e.g. increased convalescent care beds, Home First approach, Assisted Living Services for High Risk Seniors, additional community based services, Assess and Restore services, etc). urrently, the LHIN is focused on collaborating with our providers on numerous planning efforts to avoid these surge issues in the future. LHIN is undertaking a regional sub-acute planning initiative to align capacity with population need. It is anticipated that performance on this indicator will improve incrementally over the next year. MLAA 12.7 Baseline Rank Alternate Level of are (AL) Rate Lower Values are Better Trend Baseline LHIN 11.9 W T HP ES Prov (12.7) Notes: Rate based on patients occupying hospital beds during specified period. The hamplain LHIN met its target for this Alternate Level of are metric. To further improve this indicator in the future, the hamplain LHIN is collaborating with regional hospitals and providers on several planning initiatives aimed at improving patient flow in the region. A multitude of initiatives are in place to improve flow of patients out of inpatient beds (e.g. increased convalescent care beds, Home First approach, Assisted Living Services for High Risk Seniors, additional community based services, Assess and Restore services, etc). hamplain Health System Performance and Accomplishments: November

13 MLAA 16.3 Baseline Rank - 7 (tie) Lower Values are Better 2.3 Repeat Mental Health ED Visitors Trend Baseline LHIN 17.9 Prov (16.3) ES HP W T Notes: Results delayed as data from the subsequent quarter is needed to identify repeat visits up to 30 days later While the total number of mental health related emergency department visitors decreased, this was not reflected in the revisit rate. In Ottawa, the "Familiar Faces" program continues to target these re-visitors and is seeking to expand its involvement with Queensway-arleton Hospital. Planning activities including centralised access, and new program intiatives such as the Dual Diagnosis FAT Team have been initiated to re-direct the one time visitor to more appropriate services so that they do not re-visit. It is estimated that the LHIN will have closed 30 of the gap between current performance and target by the end of the fiscal year. Interventions in the planning stages today (August 2015) should have an impact on the reports available in September 2016 at which time we would expect to demonstrate that the provincial target has been met. MLAA 22.4 Baseline Rank Repeat Substance Abuse ED Visitors Lower Values are Better Trend Baseline LHIN 25.1 HP ES W T Prov (22.4) Notes: Results delayed as data from the subsequent quarter is needed to identify repeat visits up to 30 days later The re-visit rate improved since last report and hamplain LHIN moved from an eleventh place ranking to a third place ranking amongst LHINs. Recent investments in residential stabilization and coordinated access after an emergency department visit have contributed to the improvement in this indicator. In Ottawa, the "Familiar Faces" program continues to target these re-visitors and is seeking to expand its involvement with Queensway-arleton Hospital. Planning activities including centralised access, and new program intiatives such as the Dual Diagnosis FAT Team have been initiated to re-direct the one time visitor to more appropriate services so that they do not re-visit. It is estimated that the LHIN will have closed 30 of the gap between current performance and target by the end of the fiscal year. Interventions in the planning stages today (August 2015) should have an impact on the reports available in September 2016 at which time we would expect to demonstrate that the provincial target has been met. hamplain Health System Performance and Accomplishments: November

14 SAA Baseline Rank - N/A lients 6,500 6,000 5, High Priority lients Receiving A are at Home Higher values are Better 9, ,735 9, ,9 2 8 HP 6,7 3 5 T 5, , , , , ,1 6 1 ES 2,7 7 3 W 2, ,3 9 4 Trend Baseline LHIN 1, k 2.5k 5k 7.5k lients Notes: No Rank. Result is a function of LHIN size. Ontario total not shown due to scale issues. The number of high priority clients receiving A are at home has steadily increased over the past two years and the LHIN is better than its target. The success of programs such as Home First, Stay at Home, and palliative care continue to result in high acuity clients being cared for in the community. SAA 82.5 Baseline Rank Long Term are Placements for Highest Priority lients Higher values are Better ES HP W T Trend Baseline LHIN Notes: Based on clients with high or very high Method for Assigning Priority (MAPLe) scores. Long term care placement for highest priority clients is very close to the baseline and target and the Ontario average. The LHIN will continue to monitor the performance of its providers. hamplain Health System Performance and Accomplishments: November

15 IHSP 2.7 Admission to LT Homes from ommunity Higher Values are Better No comparison LHIN data to display Baseline Rank - N/A 67.5 Trend Baseline LHIN Notes: There was a slight increase in the percent of clients admitted to long-term care homes from the community and we continue to perform better than target and baseline. The LHIN will continue to monitor the performance of its providers. IHSP 9.2 Baseline Rank Patients Designated AL Who Were Discharged to Long Term are Homes Lower Values are Better W T ES HP Trend Baseline LHIN Notes: Seasonal indicator, better performance is expected in and. There was an increase in the percentage of alternate level of care (AL) patients in acute hospital beds discharged to Longterm are homes and performance did not achieve target. Active collaboration between hospitals (acute and sub-acute), the ommunity are Access entre (A) and the LHIN will ensure that in the future, patients are directed to other supportive resources such as Home are, onvalescent are, omplex ontinuous are, Rehabilitation, or ommunity Support Services. In order to improve the seasonal volume pressures at the acute hospitals, more AL patients were moved into Long-term care this quarter. This metric is expected to improve in to below 11. hamplain Health System Performance and Accomplishments: November

16 IHSP 2.1 Baseline Rank AL days Attributable to Palliative are Patients Lower Values are Better 3.4 W HP T 4.5 ES Trend Baseline LHIN Notes: hamplain performance has improved in this quarter and is better than the target and one of the best performing LHINs. The central intake process that has been implemented in Ottawa which ensures that patient referrals are sent to the most appropriate service will be formally evaluated in this fiscal year and may be expanded to other areas of hamplain. Performance will continue to be monitored and improvement strategies implemented as appropriate. MLAA 70.2 Baseline Rank - 7 per 100, Hospitalization Rate for Ambulatory are Sensitive onditions Lower Values are Better Trend Baseline LHIN W T HP ES per 100,000 Notes: Includes population aged less than 75 years. MLAA monitoring indicator, target set by hamplain LHIN. Performance on this indicator has not achieved the target. The hamplain LHIN continues to invest in initiatives that provide high quality chronic disease services across the region to prevent hospitalizations. The LHIN is working with health service providers and patient and caregiver representatives to establish ten Health Links in our region for patients with the highest complexity and service use to ensure coordination of care and quicker access to primary care and other services. Six Health Links are in implementation and to date over 60 patients with complex needs have coordinated care plans in place. The Medically omplex Patient Projects focused on patients at high risk of readmission transitioning from acute to community care completed their one-year pilot mandates. The insights and learning from these pilot projects have contributed to Health Link development and implementation of the Prescott-Russell and entral Ottawa Health Links. We expect this indicator to incrementally improve over 2015/16 as the impacts of our investments in chronic disease care are realized throughout the local health care system. hamplain Health System Performance and Accomplishments: November

17 MLAA 5.2 Baseline Rank - 7 per 1, ER Visits for onditions Best Managed Elsewhere Lower Values are Better Trend Baseline LHIN W T HP ES per 1,000 Notes: Only includes patients aged 1-74 years. MLAA monitoring indicator, target set by hamplain LHIN. The hamplain LHIN has not achieved target for this indicator. The LHIN continues to support quality improvement in primary care practices aimed at advanced access, office efficiency and chronic disease management. hamplain Health System Performance and Accomplishments: November

18 MLAA 15.5 Baseline Rank HIGH QUALITY, SAFE AND EFFETIVE ARE 4.1 Readmissions for ertain hronic onditions Lower Values are Better Trend Baseline LHIN Notes: Readmission within 30 days for stroke, chronic obstructive pulmonary disease, pneumonia, congestive heart failure, diabetes, selected cardiac conditions, selected gastrointestinal conditions.results delayed as data from the subsequent quarter is needed to identify repeat visits up to 30 days later Progress in achieving this target continues; we are above the provincial average and close to target. Regional implementation of Quality Based Procedures (QBP)s related to chronic obstructive pulmonary disease (OPD), chronic heart failure (HF) and stroke are being expanded beyond hospital to include community partners. Other projects to lower hospitalization and readmission rates for clients with chronic disease that are currently underway include a Rapid Intervention linic for heart failure patients; a community stroke rehabilitation clinic, as well as investments to expand pulmonary rehabilitation and cardiac rehabilitation services across the region. Our six Health Links are also progressing through their formative stages and are expected to realize program level impacts on their initial target populations. ross-sector partnerships between chronic disease and the mental health partners are also underway to better serve patients with multiple conditions and complex needs. The eonsult project provides primary care providers with easy access to specialist consultation across the region and continues to expand its services. By the end of fiscal 2015/16, we anticipate we will reach our LHIN target. Due to the complexity of the indicator, lag in the data and some initiatives are just getting underway, it is anticipated that the full impact of these efforts will be seen next fiscal year W ES HP T Prov (15.5) hamplain Health System Performance and Accomplishments: November

19 IHSP 20.0 Baseline Rank Early Elective Low-Risk Repeat -Sections Lower Values are Better Trend Baseline LHIN HP ES W T Notes: No Ministry target, however, target of below 20 established as part of agreements with hamplain hospitals. BORN target is 11. Performance on this indicator in 20 is below the baseline and better than the LHIN target. We are presently the best performing LHIN in the province. Activities undertaken to improve performance include: the hamplain Maternal Newborn Regional Program asked hospitals to identify physician and nurse champions to lead improvement on this indicator. Hospitals were encouraged to use this indicator as a quality indicator and to add it to their quality committee agendas. This key indicator is also addressed during the Regional Program s annual visits to hospitals and the Regional Program team is available to provide guidance or assistance. A target of below 20 has been included in 20 accountability agreements between the LHIN and the hospitals. We expect hamplain's rate to remain among the lowest in the province and to continue to decrease. IHSP 2.4 Baseline Rank omplex are Hospital Patients with New Pressure Ulcers Lower values are Better Trend Baseline LHIN W HP T ES Notes: Performance on this indicator is unchanged. hamplain remains one of the best performing LHINs. Performance trends will continue to be monitored and strategies implemented as appropriate. hamplain Health System Performance and Accomplishments: November

20 IHSP 2.4 Baseline Rank Long Term are Residents with New Pressure Ulcers Lower values are Better T 2.1 W HP Trend Baseline LHIN ES Notes: hamplain's result is unchanged over the previous quarter and is similar to average provincial performance. Trends will continue to be monitored and strategies implemented as appropriate. MLAA 42.1 Baseline Rank Physician Visit Within 7 days of Discharge Higher Values are Better Trend Baseline LHIN Notes: onditions include: Acute myocardial infarction (age 45+); ardiac conditions other than heart attack (age 40+); ongestive heart failure (age 45+); hronic obstructive pulmonary disease (age 45+); Pneumonia; Diabetes; Stroke (age 45+); Gastrointestinal disease. MLAA monitoring indicator, target set by hamplain LHIN. Performance on this indicator has not yet achieved target. Two Ministry-funded one-year demonstration projects for medically complex patients in central Ottawa and Hawkesbury have been completed. Processes and learning from these projects are being incorporated into Prescott-Russell and entral Ottawa Health Links. As Health Links become operational, improvements should be realized for those patients with the most complex needs. This indicator will continue to be monitored over the coming year W T ES HP hamplain Health System Performance and Accomplishments: November

21 IHSP Baseline Rank - 3 per 1, Hospitalization Due to Falls Among Long-Term are Residents Lower values are Better Trend Baseline LHIN HP T W , ,000 per 100,000 Notes: Number of falls per 100,000 active long-term care residents. The hamplain LHIN is implementing an integrated falls prevention program in the region that focuses on reducing falls among people in the community. For additional information on these initiatives see indicator "4.7 Fall-related emergency department visit among seniors". This indicator is linked to the overall rates of falls in long-term care homes to monitor the need for action in the coming fiscal year. IHSP Baseline Rank - 12 per 100,000 1,700 1,650 1,600 1, Fall-Related Emergency Department Visit Rate Among Seniors Lower values are Better 1, W 1, , , , , , , ES 1, ,586. T 1, , ,5 5 3 HP 1, , , Trend Baseline LHIN ,000 1,500 per 100,000 Notes: Number of falls resulting in emergency department visits per 100,000 people aged 65 or older. Includes people living in the community and in institutional settings. This quarter has seen a significant drop in the number of fall related emergency department visits among seniors and we are now achieving our target although there are still opportunities to improve as other LHINs have better rates. In 2012 the hamplain LHIN established the hamplain Regional Falls Prevention Steering ommittee to support the integration of falls prevention across the continuum of care and across the hamplain region. A Falls Prevention Algorithm was developed and standardized screening and assessment tools were piloted and adopted. In the fourth quarter, standardized screening, the algorithm and the personal support worker education module were adopted at additional sites. Primary are Network physicians all received communication related to the adoption of the algorithm in their practices. In addition, the Falls Prevention Website (stopfalls.ca/arretonsleschutes.ca) was launched. The impact of the Falls Prevention strategy and algorithm on this indicator is expected to improve over time as adoption increases across the region. hamplain Health System Performance and Accomplishments: November

22 IHSP Baseline Rank - 12 per 100, Fall-Related Hospitalization Rate Among Seniors Lower values are Better W ES T HP Trend Baseline LHIN per 100,000 Notes: The patients in indicator 4.7 that have a disposition status of admitted. These are falls with significant injury. There was a drop in the number of fall related hospitalizations among seniors and we are now close to achieving target. As described in the previous indicator, in 2012 the hamplain LHIN established a regional steering committee which is working to implement a regional strategy to reduce falls among seniors. This work is also expected to reduce serious injuries requiring visits to emergency departments and hospitalizations. hamplain Health System Performance and Accomplishments: November

23 HAMPLAIN LHIN ORGANIZATIONAL HEALTH OPS 5.1 Status of LHIN Annual Business Plan Initiatives Higher Values are Better on tra ck Baseline - None 70 Rank - N/A Trend Baseline LHIN Notes: As of the end of, all 20 ABP interventions were expected to be achieved by year-end. The ABP was approved by Board in June hamplain Health System Performance and Accomplishments: November

24 OPS 5.2 LHIN Enterprise Risk Assessment 20 None 15 # Baseline - None Rank - N/A Unmitigated Partially Mitigated Fully Mitigated 4 Notes: Includes only the risks/categories ranked as high or extreme risk by the hamplain LHIN Board. The status, after mitigation, is based on quarterly assessment by the LHIN s senior management team, ranking each risk as unmitigated (red), partially mitigated (yellow) or fully mitigated (green). The risk register was reviewed and mitigation strategies updated with new information as required. Two risk were shifted from fully mitigated (green) to partially mitigated (yellow), so now there are 4 fully mitigated, 11 partially mitigated risks. The two that changed are the risk of: "not adhering to memorandum of understanding (MOU) provisions and (Ministry-LHIN Accountability Agreement (MLAA) commitments"; and a significant reduction in Quebec revenues to health service providers due to repatriation. These changes were made to more accurately reflect the nature of the risks, such that neither are likely to ever be fully mitigated. With respect to the LHIN s accountability commitments, the recent changes to the approach to target setting for health system indicators means that the LHIN will not be in compliance over the near-term with these new stretch targets. With respect to out-of-province revenues, the LHIN is aware that at least one hospital is experiencing challenges related to out-of-province revenues. The LHIN is working with this hospital and the Ministry on this issue. OPS 5.3 LHIN Operational Budget Variance Values close to zero are better From -10 to Baseline - None -10 Rank - N/A -20 Quarter Variance umulative Variance Notes: * Actual fiscal year spending does not include Amortization and any affect of Deferred apital ontribution report, the 14/15 budget was revised to reflect the Ministry initiated $53,000 recovery from Diabetes and to reflect the additional budget provided by LHIN ollaborative joining the translation program The LHIN operational budget variance graph illustrates the quarter-by-quarter variance between actual spending during the quarter relative to the budget for that quarter. Although the quarterly budget is allocated straight-line across quarters, the actual spending pattern is not. The LHIN spends conservatively early in the fiscal year with an increase in spending in the later quarters as we become more clear about the amount of resources available. As of the first quarter of , the LHIN is tracking close to budget. hamplain Health System Performance and Accomplishments: November

25 OPS 5.5 Twitter Followers ,250 Higher Values are Better 1,350 1,000 # Baseline Rank - N/A 500 Trend Baseline LHIN Notes: Includes English plus French accounts. ounts as two if on both. The hamplain LHIN remains on target to reach its 20 goal of 1,500 Twitter followers by the end of the fiscal year. Activities this quarter included promotion of a number of important and interesting regional and provincial initiatives, such as the Minister's Medal, the opening of a regional nephrology centre in Renfrew, the My Life, My Well-Being Aboriginal report, a Rogers Health Links video featuring the hamplain LHIN O, the launch of the new hospice in Madawaska Valley and the hamplain LHIN chronic disease services video. OPS 5.6 hamplain LHIN YouTube Views Higher Values are Better ,000 1,500 # 1,000 1,002 Baseline Rank - N/A 0 Trend Baseline LHIN Notes: Number of new videos fluctuates from quarter to quarter (may be none) There was an increase in YouTube views this quarter and the LHIN has achieved its target. Further increases are expected in when new content is scheduled for posting. hamplain Health System Performance and Accomplishments: November

26 OPS 5.8 Website Traffic None 20k 15k Higher Values are Better 14,310 10k # 5k Baseline - None 0k Rank - N/A -5k Sessions Notes: Sessions are the number of unique times that a user logged on to the website. Website traffic this quarter was reduced, perhaps a reflection of the growing trend of activity shifting to social media channels. updates to the website were maintenance related, as ommunications resources were largely dedicated to other priorities. We remain on track to meet our annual goal by exploring strategies to increase website traffic. For example, website content is being refreshed to be more engaging, and links to the new content featured on our social media account (Twitter) should drive users to our website. It is important to note that the hamplain LHIN's website traffic ranks in the top three among LHINs. hamplain Health System Performance and Accomplishments: November

27 HEALTH SYSTEM FISAL MANAGEMENT AND VALUE HSFR None Baseline - None Rank - N/A Lower values are Better 6.2 A Home are ost Efficiency -1.7 Notes: Numbers below 0 indicate that actual expenses are lower than expected expenses. Excludes non-modelled expenses. Source: 20 A HBAM Results Summary from MoHLT. Additional information here. Under the Health Based Allocation Methodology (HBAM) home care module, the hamplain ommunity are Access entre's (A) total actual home care expenses were below expected. In particular, actual nursing visit expenses and actual physiotherapy expenses were below expected. These favourable variances were partially offset by unfavourable variances in nursing shift hour expenses and personal support expenses. As a result of the overall favourable variance in 20 the hamplain A received $1.9M in additional funding in 20 compared to W ES HP T SAA 0 Baseline - None Rank - N/A Values closer to zero are better 6.3 Total Margin - Hospitals Notes: figures are not requested of facilities. Figures for and are forecasted figures. Figures for show actual results. Additional information here. Nineteen of twenty hamplain LHIN hospitals recorded break-even or surplus positions for 20 consolidated operations. The remaining hospital recorded deficits in its hospital and long-term care operations and has been asked to provide a performance improvement plan. T HP W ES hamplain Health System Performance and Accomplishments: November

28 SAA 0 Baseline - None Rank - N/A Total Margin - ommunity are Access entre Values closer to zero are better Notes: figures are not requested of facilities. Figures for and are forecasted figures. Figures for show actual results. Additional information here. The hamplain ommunity are Access entre (A) recorded a surplus, due in part to misalignment of timing of incremental revenues and ramping up of service volumes. Of the total surplus of approximately $3M, $2M is recoverable due to target volumes not being reached in specific volume-funded initiatives and $1M in net surplus that will also be recovered. The LHIN is working with the A on planning efforts for the next fiscal year. HP 1.3 W T ES SAA 0 Baseline - None Rank - N/A Total Margin - ommunity Health entres Values closer to zero are better Notes: figures are not requested of facilities. Figures for and are forecasted figures. Figures for show actual results. Additional information here. At the end of the fourth quarter the sector was operating with an average margin of Ten of eleven (91) ommunity Health entres (H) completed the year with a balanced or small surplus position. One H ended the year with an insignificant margin of due to unforseen expenses. The LHIN has worked with this one H to mitigate future occurrences. W T 1.8 ES 1.6 HP hamplain Health System Performance and Accomplishments: November

29 SAA 0 Baseline - None Rank - N/A Total Margin - ommunity Support Services Values closer to zero are better Notes: figures are not requested of facilities. Figures for and are forecasted figures. Figures for show actual results. Additional information here. At the end of the fourth quarter the sector was operating with an average total margin of of 48 ommunity Support Sector Agencies completed the year with a balanced or small surplus position. Eight SS agencies ended the year with an average margin of The LHIN is engaged with these agencies to mitigate future occurrences via quarterly monitoring. ES HP T W SAA 0 Baseline - None Rank - N/A Total Margin - Mental Health and Addictions Agencies Values closer to zero are better Notes: figures are not requested of facilities. Figures for and are forecasted figures. Figures for show actual results. Additional information here. Overall, in the 4th quarter of 20 the Mental Health and Addictions Health Service Providers registered a total margin surplus of Health Service providers have achieved financial and activity targets as planned for out of 38 agencies have submitted a balanced position by end of 20. ES HP T W hamplain Health System Performance and Accomplishments: November

30 Performance Indicator Refresh Schedule Indicator Most Recent Period New Data in Board Report Timely Access to the are Needed 1.1 Time in ER for omplex Patients, Yes 1.2 Time in ER for Minor Uncomplicated Patients, Yes 1.3 Hip Replacement Wait Time, Yes 1.4 Knee Replacement Wait Time, Yes 1.5 MRI Scan Wait Time, Yes 1.6 T Scan Wait Time, Yes 1.7 Wait for Home are (ommunity lients), Yes 1.8 Personal Support Visits within 5 Days of Application, Yes 1.9 Nursing Visits within 5 Days of Application, Yes 1.10 Adults With a Primary are Provider Apr 14-Mar 15 Yes 1.11 Timely (Same / Next Day) Access to a Primary are Provider Oct 13-Sep 14 No Right are, Right Place 2.1 Patients in Acute Hospital Beds Needing Other are (AL), Yes 2.2 Alternate Level of are (AL) Rate, Yes 2.3 Repeat Mental Health ED Visitors, Yes 2.4 Repeat Substance Abuse ED Visitors, Yes 2.5 High Priority lients Receiving A are at Home, Yes 2.6 Long Term are Placements for Highest Priority lients, Yes 2.7 Admission to LT Homes from ommunity, Yes 2.8 Patients Designated AL Who Were Discharged to Long Term are Homes, Yes 2.9 AL days Attributable to Palliative are Patients, Yes 2.10 Hospitalization Rate for Ambulatory are Sensitive onditions, Yes 2.11 ER Visits for onditions Best Managed Elsewhere, Yes Positive Healthcare Experience Positive Healthcare Experience indicators under development High Quality, Safe and Effective are 4.1 Readmissions for ertain hronic onditions, Yes 4.2 Early Elective Low-Risk Repeat -Sections, Yes 4.3 omplex are Hospital Patients with New Pressure Ulcers, Yes 4.4 Long Term are Residents with New Pressure Ulcers, Yes 4.5 Physician Visit Within 7 days of Discharge, Yes 4.6 Hospitalization Due to Falls Among Long-Term are Residents, Yes 4.7 Fall-Related Emergency Department Visit Rate Among Seniors, Yes 4.8 Fall-Related Hospitalization Rate Among Seniors, Yes hamplain LHIN Organizational Health 5.1 Status of LHIN Annual Business Plan Initiatives, Yes 5.2 LHIN Enterprise Risk Assessment, Yes 5.3 LHIN Operational Budget Variance, Yes 5.4 LHIN Staff Turnover, No 5.5 Twitter Followers, Yes 5.6 hamplain LHIN YouTube Views, Yes 5.7 LHIN Employee Satisfaction, No 5.8 Website Traffic, Yes Health System Fiscal Management and Value 6.1 Hospital ost Efficiency No 6.2 A Home are ost Efficiency Yes 6.3 Total Margin - Hospitals, Yes 6.4 Total Margin - A, Yes 6.5 Total Margin - H Agencies, Yes 6.6 Total Margin - SS Agencies, Yes 6.7 Total Margin - Mental Health and Addictions Agencies, Yes hamplain Health System Performance and Accomplishments: November

31 Section D Methodology The following describes the methodology used to develop this report. Data Sources Data for the following domains are from the anadian Institute of Health Information except where otherwise stated: Timely Access to the are Needed Right are, Right Place High Quality Safe and Effective are Indicators that are identified as MLAA (indicated in the upper left corner of the graph) are calculated by the Ministry of Health and Long-Term are and provided to the LHIN. Data for the hamplain LHIN Organizational Health domain are from data collected internally at the LHIN except where otherwise stated. Data for the Health System Fiscal Management and Value domain are from the Self-Reporting Initiative (SRI) of the Ministry of Health and Long-Term are except where otherwise stated. Section D Detailed Indicator Performance Report Details on the methodology for calculating individual indicators are attached to the electronic version of the Scorecard in the technical notes, including any exceptions to the methodology shown below. Some MLAA indicators were revised in 20 and the historical values were changed to reflect new calculation methodologies. Therefore the historical data reported for these indicators will vary from previous Board reports. Baseline Baselines are the average performance from the previous year (usually fiscal year) where available. The methodology for baseline colour coding is as follows: Green: Yellow: Red: Gray: LHIN is better than or equal to baseline LHIN is within 10 of the baseline LHIN is worse than baseline No baseline hamplain Health System Performance and Accomplishments: November 2015 D1

32 Rank hamplain s rank is based on a numerical ordering of all the other LHINs with a rank of 1 being the top performing LHIN in Ontario and 14, the worst. A tie with another LHIN will be given the same rank. For example, if 2 LHlNs are tied for #7, both are given a rank of 7 and the next best LHIN will be given a rank of 9. olour coding of rank is based on the comparison with 14 other LHINs as follows: Green: Yellow: Red: Gray: 1 st to 7 th 8 th to 11 th 12 th to14 th Rank not applicable Setting Approach s The colour coding for the targets is based on the following: Green means that the LHIN result has met its target Yellow means that the LHIN result is within 10 of achieving target Red means that the LHIN result is more than 10 from its target Gray indicators do not have a target. s were set based on the following approach: 1. Indicators contained in the Ministry LHIN Accountability Agreement (MLAA) These targets are set provincially by the Ministry. Indicators with sufficient data/information If sufficient information is available, the target is set based on the previous year s baseline for the hamplain LHIN. If hamplain s performance is among the top 7 ranked LHINs, the target will be set to the 7 th best LHIN s performance for the previous year. If performance is among the bottom 7 LHINs, the target will be set to improve performance to a level determined by a natural log formula. 2. Indicators with partial data For indicators with partial data available, targets have been set based on industry best practice and/or historical evidence. 3. Indicators with insufficient data For indicators where there is no industry standard and insufficient historical evidence, no target has been proposed. Once more data are available, a baseline and target will be set, if appropriate. hamplain Health System Performance and Accomplishments: November 2015 D2

33 Section E Acronyms A T HSAA HSFR IHSP LSAA MLAA MRI MSAA OPS Q SAA ommunity are Access entre omputed Tomography Hospital Services Accountability Agreement Health System Funding Reform Integrated Health Services Plan Long-Term are Accountability Agreement Ministry-LHIN Accountability Agreement Magnetic Resonance Imaging Multi-Sectoral Accountability Agreement Operations Fiscal Quarter Service Accountability Agreement hamplain Health System Performance and Accomplishments: November 2015 E1

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