Hospital Care Indicators

Transcription

1 Hospital Care Indicators Common Quality Agenda DRAFT - DO NOT CIRCULATE 1

2 Hospital Care Indicators There are 23 Common Quality Agenda indicators that are relevant to the hospital care sector, the largest of all sectors. Accountability for 12 of these is specific to hospital care organizations; an additional 11 indicators have shared accountability with other sectors. Hospital care indicators Accountability Target Target source Percentage of hip and knee replacements completed within target by priority level (E) (CD) Hospital 182 days (provincially set) Provincial government Percentage of patients discharged to inpatient rehabilitation following the index stroke admission (N) (CD) Percentage of hospitalized stroke patients who are admitted to a stroke unit (N) (CD) Percentage of complex continuing care (CCC) residents with a new stage 2 or higher pressure ulcer in the last three months (E) (CD) Percentage of complex continuing care (CCC) residents who fell in the last 30 days (E) (CD) Percentage of patients who would definitely recommend hospital to family and friends -inpatient -ED (E) (CD) Percentage of STEMI patients with acute coronary syndrome whose door to balloon time was within provincial (CCN) benchmark (<90 minutes if presenting to PCI hospital; <120 minutes if presenting to non-pci hospital). (N) (CD) Percentage of procedures completed within target time period for patients designated as: urgent; semi; elect Coronary artery bypass graft (CABG) Percutaneous coronary intervention (PCI) Angiography (E) (CD) Hospital Hospital 42% (set by SEQC); year over year = 10% 87.5% (set by SEQC); year over year = 10% SEQC SEQC Hospital 1.6% HQO benchmarking Hospital 5%; 10% year over year relative reduction Hospital 70.6% (ED) 5% relative improvement year over year 81.8% (inpatient) 5% relative improvement year over year Hospital 90% for patients presenting to PCI hospitals 80% of patients presenting to non- PCI hospitals Hospital Wait times as set by CCN RMWT PCI / Angio -Urgent (7 days) -Semi-urgent (14 days) -Elective (28 days) RMWT (CABG) -Urgent (14 days) -Semi-urgent (42 days) -Elective (90 days) HQO benchmarking HQO benchmarking CCN (guidelines based) Provincial government with CCN Common Quality Agenda DRAFT - DO NOT CIRCULATE 2

3 Wait times for cancer consult and surgery - % within target for cancer surgery; - wait time for radiation treatment (ready to treat to treat); - wait time for systemic treatment -----referral to consult -----consult to treatment (E) (CD) Hospital 90 th percentile wait time for cancer surgery = 14, 28, 84 days depending on priority Wait times for radiation - ready to tx to tx = 1, 7 or 14 days depending on priority Provincial government with CCO Hospital-acquired C. diff infection (CDI) rate per 1000 patient days (E) (PH) 90th percentile length of stay in ED (E) (PH) Hospital Hospital Systemic therapy: Referral to consult = 67% within target values Consult to treatment = 85% within target values 10-20% year over year Try to get below 0.3 (Ministry set benchmark) 90% of patients who are either low acuity or who are not admitted should have a LOS < 4hours 90% of patients who are either high acuity or who are admitted should have a LOS < 8hours Expert consultation Provincial government Prevalence of physical restraint use for mental health and addictions patients in hospital (N) (MH) Admission rates for conditions that are sensitive to outpatient (ambulatory) care delivery (CHF, COPD, diabetes, asthma) (R) (CD) Percentage of ALC days in acute care hospitals (E) (CD) Lost-time and non-lost time injury rates per 100 full-time equivalent health care workers (E) (CD Hospital Hospital/Primary Care/Long-Term Care/Home Care Hospital/Primary Care/Long-Term Care/Home Care Hospital/Primary Care/Long-Term Care/Home Care 0% (50% relative reduction year over year) 20% relative reduction year over year 9.46% - 10% year over year relative reduction Context Expert consultation Expert panel consultation Provincial government Context indicator Common Quality Agenda DRAFT - DO NOT CIRCULATE 3

4 Psychiatric rehospitalisation rate within 30 days (R) (MH 30-day unplanned all-cause readmission rate after hospital discharge to community (index: CHF, COPD, DM, AMI, Asthma, stroke) (R) (CD) Percentage of patients seeing a primary care provider or a specialist within 7 days of discharge after an inpatient stay for a mental health and addictions condition (R) (MH) Percent of patients with COPD who have had their diagnosis confirmed with pulmonary function testing (N) (CD) Office visit 7 days following in-patient discharge for heart failure patients (any provider, primary care provider, cardiologist) COPD patients (any provider, primary care provider, respirologist) (N) (CD) Early elective repeat c-section among lowrisk women before 39 weeks gestation (N) (PH) Induction prior to 41 weeks gestation with an indication of post-dates (N) (PH) Home care wait time : - time from inpatient discharge - time from community referral (E) (PH) Hospital/Primary Care/Long-Term Care/Home Care Hospital/Primary Care/Home Care Hospital/Primary Care/Long-Term Care Hospital/Primary Care Hospital/Primary Care Hospital/Primary Care Hospital/Primary Care Hospital/Home Care % (10-15% year over year relative reduction) 10% year over year for CHF and COPD; stroke goal is to keep below 10% (current performance = 8.6%); Confirming asthma DM AMI targets 75% (10-15% relative improvement year over year) 80%; 20% year over year relative improvement 50% relative improvement year over year for HF patients Confirm for COPD patients BORN set target of <11.0%; with warning rate set at between % BORN set target of <5.0%; with warning rate set at between % Hospital to HC wait time Expert panel consultation Expert consultation (Note SEQC 2012 report indicates stroke readmit benchmark is 8%) Expert panel consultation Expert panel consultation Expert panel consultation BORN Ontario BORN Ontario No target set Common Quality Agenda DRAFT - DO NOT CIRCULATE 4

5 Percent of Hip/Knee Replacements Completed within Target by Priority Level Indicator This is the percent of patients who met the access targets from when description a patient and surgeon decide to proceed with surgery (decision-totreat) until when the actual procedure is completed. The access targets are as follows for each of the priority levels: Priority 2: 42 days Priority 3: 84 days Relevance/ Rationale Reporting tool/product Attribute Type External Alignment Accountability Calculation Priority 4: 182 days Hip/knee replacement is one of high priority areas to reduce wait times. Collecting and reporting accurate and up-to-date data on wait times allow better decision making and increase accountability. Quality Monitor annual report Accessible Process and core indicator HQO Quality Based Procedures; Ontario s Action Plan for Health Care (Access); H-SAA; May also align with Health Links; Ministry Quarterly Report Hospital Numerator Number of patients whose surgery wait times is within the access targets. (See wait times calculation & access targets below.) Wait time (in days) = "treatment" date minus "decision to treat" date The wait time is calculated for each patient who received treatment within the most current time period. Access targets: Priority 2: 42 days Priority 3: 84 days Priority 4: 182 days Denominator All hip or knee replacement surgeries meeting the inclusion/exclusion criteria below. Inclusion Criteria: All closed wait list entries with procedure dates within date range; Patient was 18 years or older on the day the procedure was completed. Exclusion Criteria: Procedures no longer required. Procedures assigned as Priority 1 level. Wait list entries identified by hospitals as data entry errors. Other Criteria: If patient unavailable dates fall outside the Decision to Treat Date up to Procedure Date, the patient unavailable dates are not Common Quality Agenda DRAFT - DO NOT CIRCULATE 5

6 Data source / data elements Timing and frequency of data release Levels of comparability Targets and/or Benchmarks deducted from the patient's wait days. These are considered data entry errors. Wait Times Information System (WTIS), CCO; Hospitals submit their information electronically directly to WTIS; Several activities ensure data accuracy and its compliance with established reporting guidelines for WTIS data. Please refer to the following website for details: ata.aspx#2 Reported at overall hospital facility, LHIN, and provincial levels. Monthly, quarterly and yearly data are requested from CCO; and yearly data are reported in QMonitor reports Across time; Facility and LHIN level comparisons Hip/ Knee Replacement 42 days priority 2 84 days priority days priority 4 Target Source Provincial Wait Times Strategy Limitations Small volumes: small number of cases within a certain reporting period may have a big impact on the result, and thus makes it difficult to draw conclusions about what should be expected Other Factors Affecting Wait Times: There are factors that affect wait times that do not relate to a hospital s efficiency, to a particular doctor or the availability of resources. They include : o o o o Patient Choice a patient with a non-life-threatening condition may decide to delay treatment for personal or family reasons to a more convenient time. Patient Condition a patient s condition may need to improve before the surgery or exam takes place. Follow-up Care a patient who has an existing condition may be pre-booked for a follow-up treatment or exam a long time in advance. Treatment Complexity a patient with special requirements may need specific equipment or a certain kind of facility and there is a delay until these can be scheduled. Right now, there is no way to capture all of these possible factors in the information that hospitals are reporting. However, the provincial Wait Time Information System (WTIS) will collect information about when patients are not available for treatment. Although these factors may have a significant effect on the wait time for an individual patient, overall wait times are still a good reflection of the current situation for a typical patient at that hospital. Common Quality Agenda DRAFT - DO NOT CIRCULATE 6

7 Percent completed within target Adjustment (risk, age/sex standardization) Guidelines, SOPs, Evidence for best practice Not adjusted n/a Current performance Figure1. Percent of hip replacements completed within target time by priority level, FY2008/ /12, Ontario 100% % Total Volume (cases) 0% 2008/ / / /12 Total Volume (cases) Priority 2 (42 days) 62% 63% 62% 66% Priority 3 (84 days) 67% 68% 66% 67% Priority 4 (182 days) 86% 90% 87% 85% 0 Common Quality Agenda DRAFT - DO NOT CIRCULATE 7

8 Figure2. Percent of hip replacements completed within target time by priority level and LHIN, FY2011/12 100% Percent completed within target Percent completed within target 50% 0% ESC SW WW HNH B CW MH TC C CES SE CH NSM NE NW Priority 2 (42 days) 100% 67% 71% 56% 100% 86% 69% 89% 66% 77% 48% 75% 18% 89% Priority 3 (84 days) 88% 49% 71% 61% 55% 77% 72% 77% 67% 66% 69% 65% 48% 84% Priority 4 (182 days) 92% 79% 80% 78% 86% 93% 93% 95% 93% 95% 67% 95% 82% 83% Figure3. Percent of hip replacements completed within target time by facility, Priority level 2, FY2011/12 100% Performance target for priority level 2 = 42 days 50% 0% Facility as per hip replacement figures Note: Facilities with NV and NA are excluded from figure Common Quality Agenda DRAFT - DO NOT CIRCULATE 8

9 Percent completed within target Figure4. Percent of hip replacements completed within target time by facility, Priority level 3, FY2011/12 100% Performance target for priority 3 = 84 days 50% 0% Facility as per hip replacement figures Note: Facilities with NV and NA are excluded from figure Common Quality Agenda DRAFT - DO NOT CIRCULATE 9

10 Figure5. Percent of hip replacements completed within target time by facility, Priority level 4, FY2011/12 100% Percent completed within target Percent completed within target Performance target for priority 4 = 182 days 50% 0% Facility as per hip replacement figures Note: Facilities with NV and NA are excluded from figure Figure6. Percent of knee replacements completed within target time by priority level, FY2008/ /12, Ontario 100% % % 2008/ / / /12 Total Volume (cases) Priority 2 (42 days) 60% 62% 60% 64% Priority 3 (84 days) 63% 65% 62% 60% Priority 4 (182 days) 82% 88% 86% 80% 0 Common Quality Agenda DRAFT - DO NOT CIRCULATE 10

11 Percent completed within target Figure7. Percent of knee replacements completed within target time by priority level and LHIN, FY2011/12 100% 50% 0% ESC SW WW HNH B CW* MH* TC C CE SE CH NSM NE NW* Priority 2 (42 days) 91% 75% 70% 56% 73% 95% 61% 65% 46% 73% 27% Priority 3 (84 days) 82% 39% 64% 53% 68% 76% 67% 73% 59% 60% 53% 67% 42% 67% Priority 4 (182 days) 91% 69% 65% 67% 85% 86% 90% 91% 94% 94% 63% 95% 70% 73% * For priority level 2, those LHINs have no data due to no or low volume during the reporting period. Common Quality Agenda DRAFT - DO NOT CIRCULATE 11

12 Percent completed within target Figure8. Percent of knee replacements completed within target time by facility, Priority level 2, FY2011/12 100% Performance target for priority 2 = 42 days 50% 0% Facility as per knee replacement figures Note: Facilities with NV and NA are excluded from figure Common Quality Agenda DRAFT - DO NOT CIRCULATE 12

13 Figure9. Percent of knee replacements completed within target time by facility, Priority level 3, FY2011/12 100% Performance target for priority 3 =84 days Percent completed within target 50% 0% Facility as per knee replacement figures Note: Facilities with NV and NA are excluded from figure Common Quality Agenda DRAFT - DO NOT CIRCULATE 13

14 Percent completed within target Figure10. Percent of knee replacements completed within target time by facility, Priority level 4, FY2011/12 100% Performance target for priority 4 = 182 days 50% 0% Facility as per knee replacement figures Note: Facilities with NV and NA are excluded from figure Statement of results Hip Replacements The volume of hip replacements has increased by more than 10% between 2008/09 and 2011/12. The time trends for the percent of procedures completed within target has varied by priority level. The percent of urgent hip replacements (priority level 2) completed within the 42 days target increased from 62% to 66% over the past four years. The percent of semi-urgent (level 3) hip replacements completed within the 84 days target has remained relatively stable. The percent completed within target for elective (level 4) hip replacements increased between 2008/09 to 2009/10, and since then has decreased. There was wide variation across LHINs for all priority levels in fiscal year 2011/12 (see Figure 2). Overall, Erie-St. Clair LHIN had the best performance among all LHINs. There was less facility level variation in the percent of elective cases completed within target compared with the variation seen for semi-urgent and urgent cases. In 2011/12, there were six facilities where less than 50% of urgent cases were completed within target and 12 facilities for semi-urgent cases within target. Facility level variation for elective cases was narrower the percent of elective cases completed within target was between 40% and 100%, and only 3 facilities had less than 50% completed within target. Common Quality Agenda DRAFT - DO NOT CIRCULATE 14

15 Knee Replacements The volume of knee replacements has increased by more than 10% between 2008/09 and 2011/12. The trend over time in the percent of knee replacements completed within target has varied by priority level. The percent of urgent knee replacements (priority level 2) completed within the 42 days target increased from 60% to 64% over the past four years. The percent of semi-urgent (level 3) and elective (level 4) knee replacements completed within target have slightly decreased over the same time period. There was wide variation across LHINs for all priority levels in fiscal year 2011/12 (see Figure 7). Overall, Erie-St. Clair LHIN and Central LHIN had better performance compared to other LHINs. There was facility level variation for all priority levels. In 2011/12, for example, the percent of semi-urgent cases (level 3) completed within target was between 11% and 100%. Common Quality Agenda DRAFT - DO NOT CIRCULATE 15

16 Percent of stroke patients discharged to inpatient rehabilitation following an acute stroke hospitalization Indicator In many cases, stroke patients should be discharged from an acute description stroke hospitalization to inpatient rehabilitation to ensure full recovery Relevance/ Rationale potential is achieved (Rationale taken from Canadian Best Practice Recommendations for Stroke Care Reporting tool/product Attribute Type External Alignment Accountability Calculation There is strong and compelling evidence in favour of admitting patients with moderate and severe stroke to a geographically defined stroke rehabilitation unit staffed by an interprofessional team. Death and disability are reduced when post-acute stroke patients receive coordinated, interprofessional evaluation and intervention on a stroke rehabilitation unit. For every 100 patients receiving organized inpatient interprofessional rehabilitation, an extra five return home in an independent state. Qmonitor; Stroke Evaluation and Quality Committee Report Effective Process indicator and core indicator Quality Based Procedures condition-specific indicator H-SAA; Ontario Stroke Audit Hospital Numerator Stroke Patients (Most Responsible Diagnosis ICD10 code = I60, I61, I63, I64) Discharge Disposition not equal to 07 (dead) in the DAD and linking them to the NRS. Admitted and classified RCG=1 in the same fiscal year as the DAD discharge Denominator For each fiscal year take the first stroke hospitalization discharge of a unique patient. Stroke Patients (Most Responsible Diagnosis = I60 (subarachnoid haemorrhage), I61 (intracerebral haemorrhage), I63 (cerebral infarction), I64 (stroke not specified)) discharged disposition not equal 07 (died) Excludes: 1. ICD-10-CA Diagnostic codes I60.8 (other subarachnoid hemorrhage), I63.6 (cerebral infarction due to cerebral venous thrombosis, nonpyogenic) 2. Discharge disposition = died (07) 3. Age is less than Two different exclusions are applied depending on its use: a) Individuals with missing LHIN (used for SEQC report for provincial rates) or b) Individuals with missing sublhin (used for SEQC report for benchmarking) Common Quality Agenda DRAFT - DO NOT CIRCULATE 16

17 Data source / data elements Timing and frequency of data release Levels of comparability Targets and/or Benchmarks Target Source Limitations Adjustment (risk, age/sex standardization Guidelines, SOPs, Evidence for best practice Comments NRS and CIHI-DAD Data are released annually in December and available as of LHIN (using patient s postal code to assign to LHIN, i.e., LHIN performance is the proportion of patients that live in the LHIN that received inpt rehab following an acute stroke inpatient stay) 42.3% based on target values set by the SEQC and reported in the Ontario Stroke Evaluation Report This target was confirmed in consultations with ICES and Ontario Stroke Registry 10% year-over-year relative improvement based on recommendations from ICES SEQC and expert consultation Only looks at stroke patients admitted into the NRS in the same FY as the DAD discharge therefore the numerator does not capture those patients discharged at the end of the FY from the DAD database. Nor does it capture those patients that received inpatient rehab in facilities that do NOT report to the NRS Unable to exclude patients who had mild strokes Stratified by sex, age group, income quintile, rural/urban, LHIN and sublhin Risk adjusted using age and gender (indirect standardization) Canadian Best Practice Recommendations for Stroke Care Ontario Stroke Evaluation Report 2012: Prescribing System Solutions to Improve Stroke Outcomes (exhibit 3.4) gsec_id=0&item_id=7543&type=report Ontario Stroke Evaluation Report 2013: Spotlight on Secondary Stroke Prevention and Care (exhibit 5.3) * The OSN reports a LHINs performance using a patient-based analysis. Postal-code of patient is used to assign patient to their LHIN. *Multiply by 100 to present as a percent 1 The benchmarks referenced in the Ontario Stroke Evaluation Reports are recalculated annually using the ABC methodology and facility/sub-lhin data. For benchmarking methodology, see Weissman et al. Journal of Evaluation in Clinical Practice 1999; 5(3): The Ontario Stroke Evaluation Report 2013 provides an updated benchmark of 42.6% Common Quality Agenda DRAFT - DO NOT CIRCULATE 17

18 Adjusted rate per 100 Current Performance Note: Graphs are generated using adjusted rates and exclusion 4a (Individuals with missing LHIN information are excluded) Figure 1: Percent of patients discharged to inpatient rehabilitation following the index stroke admission, per fiscal year, excluding missing LHINs 60.0 Performance Target = 42.3% Target relative year-over-year improvement = 10% / / / / / / / / /12 Data source: NRS & CIHI-DAD, provided by ICES Common Quality Agenda DRAFT - DO NOT CIRCULATE 18

19 Figure 2: Percent of stroke patients discharged to inpatient rehabilitation following the index stroke admission in fiscal year 2011/12 by LHIN, excluding missing LHINs 50.0 Performance Target = 42.3% Target relative year-over-year improvement = 10% Adjusted rate per ESC SW WW HNHB CW MH TC C CE SE CH NSM NE NW Data source: NRS & CIHI-DAD, provided by ICES Common Quality Agenda DRAFT - DO NOT CIRCULATE 19

20 Figure 3: Percent of stroke patients discharged to inpatient rehabilitation following the index stroke admission in fiscal year 2011/12 by sublhin, excluding missing LHINs 60 Performance Target = 42.3% Target relative year=over-year improvement = 10% Adjusted rate per Data source: NRS & CIHI-DAD, provided by ICES Table 1: Percent of stroke patients discharged to inpatient rehabilitation following their index stroke admission in fiscal year 2011/12, by patient characteristics (excluding patients with missing LHIN) Variable Category Adjusted rate per 100 Adjusted 95% LCL Adjusted 95% UCL Sex Age Income Quintile Rural F M st (lowest) nd rd th th (highest) N Y Common Quality Agenda DRAFT - DO NOT CIRCULATE 20

21 Statement of Results The age, sex-adjusted percent of hospitalized stroke patients who were discharged to inpatient rehabilitation increased from 27.8% in 2003/04 to 31.5% in 2011/12 (Figure 1). The percent of hospitalized stroke patients who were discharged to inpatient rehabilitation showed a 15% difference between the best performing LHIN (Northwest LHIN; 38.9%) and the worst performing LHIN (Central LHIN; 24.0%) in 2011/12 (Figure 2). The sub-lhin variation was also large: of the 97 sub-lhin regions, the 10 th percentile adjusted rate was 16.5% and the 90 th percentile adjusted rate was 41.5% (Figure 3, data values not shown). There were statistically significant differences in inpatient rehabilitation rates by age, but not by sex, neighbourhood income quintile or rural/urban status (Table 1). In 2011/12, there tended to be smaller proportions of the youngest (18-45 year olds; 20.9%) and oldest (85+ year olds; 26.0%) stroke patients who were discharged to inpatient rehabilitation compared to those between the ages of (33.0% to 33.8%). Patients who lived in rural areas (29.1%) were slightly less likely to be admitted to inpatient rehabilitation than those living in urban areas (31.9%); however this difference was not significant. Common Quality Agenda DRAFT - DO NOT CIRCULATE 21

22 Percent of stroke and transient ischemic attack (TIA) patients admitted to a stroke unit during their inpatient stay Indicator All hospitalized stroke / TIA patients should be admitted to a stroke unit description for acute stroke management for improved outcomes. Relevance/Ratio There is strong evidence that the use of stroke care units improve nale outcomes of stroke patients who are hospitalized. Research has shown that stroke care units can decrease the likelihood of disability and death by as much as 30%. Taking-Action-Resource-OVERVIEW_EN_22May13F.pdf Reporting tool/product Attribute Type: External Alignment Accountability Calculation This indicator was recommended for performance measurement in the Quality-Based Procedures: Clinical Handbook for Stroke ( QMonitor; Stroke Evaluation and Quality Committee Report Effective Process indicator and core indicator Quality Based Procedures; H-SAA; Ontario Stroke Audit; Stroke Evaluation and Quality Committee Report Hospital Numerator Number of stroke or TIA inpatients >= 18 years of age treated on an acute stroke unit at any time during hospital stay [HC_Admitted] = Stroke Unit OR [D_StrokeUnit] = Yes Denominator All patients >= 18 years of age admitted to an acute care facility in Ontario with a diagnosis of stroke or TIA (ICD-10-CA codes I60 (excluding 160.8), I63 (excluding I63.6), I64, H34.1, I61 and G45 (excluding G45.4)) [FD=DCDiagnosis] = stroke or TIA [D_AdmitSame] = yes Data source / data elements Timing and frequency of data release Exclusion 1. Age is less than Inhospital stroke [SE_inHospitalStroke] = yes Ontario Stroke Audit 2010/11 Note: for subsequent years, we will be able to use DAD - As of FY2012/13 stroke unit data element is mandatory in the Discharge Abstract Database (DAD) Stroke unit admission is determined according to the fifth character (Y, N, 8) of variables, Project1~Project5. Y=Yes, N=No, 8=Facility does not have a designed stroke unit. Data are available biennially in February for data from Ontario Stroke Audit Common Quality Agenda DRAFT - DO NOT CIRCULATE 22

23 Levels of comparability Targets and/or Benchmarks Target Source Limitations Adjustment (risk, age/sex standardization) Data available annually through Ontario Stroke Network or hospitals can generate as often as they like through their decision support team. Data are available as of 2002 in the Ontario Stroke Audit and as of 2012/13, Stroke unit admission will be captured in the DAD Data are available at the level of the facility 87.5% based on target values set by the SEQC and reported in the Ontario Stroke Evaluation Report This target was confirmed in consultations with ICES and Ontario Stroke Registry. 10% year-over-year relative improvement based on recommendations from ICES SEQC and expert consultation Ontario Stroke Audit is biennial and includes a sample of charts; the sampling strategies differ by year Sampling strategies differ by year: Ontario Stroke Audits in 2002/03, 2004/05, 2008/09 were conducted on a random sample of 20% of all eligible cases, with oversampling performed at low-volume institutions (fewer than 33 annual visits or admissions for stroke or TIA) where each contributed a minimum of 10 cases and at District Stroke Centres where each contributed a minimum of 50 cases. Ontario Stroke Audit in 2010/11 was conducted based on a populationbased sampling strategy that included: 100% sample of all cases from Regional, Enhanced, and District Stroke Centres; 100% sample of all cases seen at the non-designated hospitals where Telestroke consultations are initiated; 30% random sample of all cases from non-designated hospitals that have >100 adult stroke/tia cases per year, 30 random adult charts from hospitals that have adult stroke/tia separations per year and, 10 random adult charts from hospitals that have <33 adult stroke/tia separations per year Weighting: To account for oversampling at certain institutions, results were weighted based on hospital volume and the number of charts sampled. The weight assigned to a record was inversely proportional to the probability of that record being selected for inclusion in the study. By using weights in the analyses, an estimate that applied to the entire population of discharge records was obtained. Adjustment: 2 The benchmarks referenced in the Ontario Stroke Evaluation Reports are recalculated annually using the ABC methodology and facility/sub-lhin data. For benchmarking methodology, see Weissman et al. Journal of Evaluation in Clinical Practice 1999; 5(3): The benchmark in the Ontario Stroke Evaluation Report 2013 is the same as 2012 (87.5%) Common Quality Agenda DRAFT - DO NOT CIRCULATE 23

24 Weighted, adjusted rates were calculated using an indirect standardization methodology: weighted risk adjusted rate for a subgroup = weighted crude rate for that subgroup/weighted predicted rate* overall weighted crude rate. The predicted rate and overall weighted crude rate were generated by running a survey logistic regression model with age and gender. The confidence interval for the weighted adjusted rate was from 1000 iteration bootstraps. Guidelines, SOPs, Evidence for best practice Comments Indicator results are stratified by: sex, age group, income quintile, Ontario Stroke System hospital designation, LHIN and institution Canadian Best Practice Recommendations for Stroke Care Ontario Stroke Evaluation Report 2012: Prescribing System Solutions to Improve Stroke Outcomes (exhibit 2.4) gsec_id=0&item_id=7543&type=report Common Quality Agenda DRAFT - DO NOT CIRCULATE 24

25 Percent Current performance 3 Figure1. Percent of stroke patients admitted to a stroke unit during their inpatient stay per fiscal year, weighted adjusted rates, Ontario, FY 2002/03, FY 2004/05, FY 2008/09, FY2010/ % Performance Target = 87.5% Target relative year-over-year improvement = 10% 50.0% 0.0% 2002/ / / / /11 Weighted Adjusted Rate 2.8% 18.1% 29.4% 38.1% Data Source: Ontario Stroke Audit Acute, provided by ICES Note: Acute Ontario Stroke Audits are conducted biennially. The sampling strategy differs between the earlier years (2002/03, 2004/05, and 2008/09) and the most recent audit (2010/11). Results for 2006/07 are not available. 3 Note: The graphs and table are generated using weighted adjusted rates. The weighted adjusted rates differ from the weighted crude rates by at most 1%, but the adjusted confidence limits are wider than the crude confidence limits. The characteristics with significantly different percents of patients admitted to stroke unit (e.g., hospital designation) are the same for weighted crude and adjusted results. Common Quality Agenda DRAFT - DO NOT CIRCULATE 25

26 Percent Figure2. Percent of stroke patients admitted to a stroke unit during their inpatient stay, weighted adjusted rates, stratified by LHIN, FY2010/11; Data Source: Ontario Stroke Audit Acute, provided by ICES 100% Performance Target = 87.5% Target relative year-over-year improvement = 10% 50% 0% ESC SW WW HNHB CW MH TC C CE SE CH NSM NE NW Weighted Adjusted Rate 59.8% 43.4% 41.2% 26.7% 16.4% 34.6% 38.1% 37.9% 31.1% 48.8% 50.4% 23.4% 40.0% 69.4% Common Quality Agenda DRAFT - DO NOT CIRCULATE 26

27 Percent Figure3. Percent of stroke patients admitted to a stroke unit during their inpatient stay, weighted adjusted rates, stratified by institution with a stroke unit, FY2010/11; Data Source: Ontario Stroke Audit Acute, provided by ICES 100% Performance Target = 87.5% Target relative year-over-year improvement = 10% 50% 0% Non-designated District stroke centre Regional stroke centre Enhanced district stroke centre Note: A) There were 35 institutions identified as having stroke units based on Appendix E Institutional Resources for Stroke in Ontario, 2011/12 4. There were an additional three institutions identified as having a stroke unit in the appendix that were not within the data provided by the Ontario Stroke Audit (Windsor Regional Hospital (Western), University Health Network (Western), and Mackenzie Richmond Hill Hospital). B) The first eight institutions have a rate of 0%. Six are non-designated stroke centres and 2 are district stroke centres. 4 Ontario Stroke Evaluation Report 2013: Spotlight on stroke prevention and care Common Quality Agenda DRAFT - DO NOT CIRCULATE 27

28 Table1. Percent of stroke patients admitted to a stroke unit during their inpatient stay, weighted adjusted rates, by age group, sex, income quintile, rural/urban, and OSS Hospital Designation, FY2010/11; Data Source: Ontario Stroke Audit Acute, provided by ICES Variable Stratification Weighted adjusted rate (%) 95% LCL (%) 95% UCL (%) Age % 33.0% 41.9% % 36.1% 39.6% % 37.3% 41.7% % 36.5% 40.2% % 35.5% 39.7% Sex Female 38.3% 37.2% 39.3% Male 38.3% 37.2% 39.3% Income quintile 1 st (Lowest) 38.4% 36.0% 40.7% 2 nd 38.2% 35.9% 40.5% 3 rd 38.0% 35.6% 40.6% 4 th 36.9% 34.5% 39.3% 5 th (Highest) 39.8% 37.2% 42.5% Rural/ Urban Urban 39.6% 38.5% 40.8% Rural 30.2% 27.9% 32.7% OSS Hospital Designation Regional Stroke Centre 63.9% 62.3% 65.5% Designated Stroke Centre 63.3% 61.6% 65.0% Non-designated 7.0% 5.8% 8.2% Statement of results The biennial Acute Ontario Stroke Audit (OSA) results show that the weighted adjusted percent of hospitalized stroke patients who were admitted to a stroke unit during their inpatient stay has increased from 3% in 2002/03 to 38% in 2010/11 (Figure 1). There is significant LHIN variation in the weighted adjusted rate of stroke patients admitted to a stroke unit, ranging from 16% (Central West LHIN) to 69% (North West LHIN) (Figure 2). The weighted adjusted rate of hospitalized stroke patients who were admitted to a stroke unit during their inpatient stay does not vary by age, gender, or neighbourhood income quintile, but does vary significantly by rurality (Table 1). Patients living in urban Ontario represent approximately 85% of hospitalized stroke patients. The patients who lived in urban Ontario were more frequently admitted to a stroke unit compared to patients who lived in rural Ontario, with rates of 40% and 30%, respectively (Table 1). There were approximately stroke patients hospitalized in regional stroke centres (4 124 patients), designated stroke centres (2 918 patients) or non-designated stroke centres (5 733 patients). Thirty eight institutions have stroke units: 25 stroke units are in regional, enhanced district, or district stroke centres and 13 stroke units are in nondesignated stroke centres. Over 60% of the patients hospitalized in stroke centres were Common Quality Agenda DRAFT - DO NOT CIRCULATE 28

29 admitted to a stroke unit; however, only 7% of patients hospitalized in non-designated stroke centres were admitted to stroke units (Table 1). Even after limiting to hospitals with stroke units, there was institutional variation in the percent of hospitalized stroke patients admitted to stroke units, ranging from 0% to 90% (Figure 3). Eleven of the institutions with stroke units admitted 0-15% of stroke patients to stroke units, 16 of the institutions admitted 40-70% of stroke patients to stroke units, and 8 of the institutions admitted 75-90% of stroke patients to stroke units. Common Quality Agenda DRAFT - DO NOT CIRCULATE 29

30 Relevance/ Rationale Percent of complex continuing care (CCC) residents with new stage 2 or higher pressure ulcer in the last three months Indicator This indicator measures the proportion of CCC patients that description developed a new stage 2 or higher pressure ulcer in a threemonth period. This is an important indicator because the development of pressure ulcers increases a patient s risk of serious infection and can have a negative impact on independence and mental health. Reporting CIHI e-reporting portal to data submitters tool/product Attribute Safe Type Outcome and core indicator External QIP- Acute care sector Alignment Accountability Hospital Calculation Numerator Residents who had a new pressure ulcer at stages 2 to 4 on their target assessment Denominator CCC Residents with at least 2 valid assessments, excluding those with stage 2 to 4 pressure ulcers on their prior assessment Data source / data elements Timing and frequency of data release Levels of comparability Targets and/or The indicators are derived from RAI-MDS 2.0 through CIHI s Continuing Care Reporting System (CCRS), a reporting system that contains demographic, administrative and clinical information for residents from residential care and hospitalbased continuing care facilities across Canada Data elements used: o M2a Stage of Pressure Ulcer o Prev_M2a Stage of Pressure Ulcer CIHI reported the facility level quarterly data on e-reporting tool. Data submitters can access their data. HQO has access as well through data portal. Data updated by CIHI on e-reporting tool every quarter LHIN level and provincial data were available through data request Across time; by LHIN and facility (facility data are on CIHI portal; need CIHI permission for public reporting); QIP Benchmark: 1.6% Benchmarks Target Source HQO benchmarking process (2012) + expert consultation Limitations While rolling four quarter averages stabilize the rates from quarter-to-quarter variations, especially for smaller facilities, it is makes it more difficult to detect true quarterly improvements Adjustment (risk, age/sex standardization) Risk adjustment at two levels: Adjusted at individual resident level using logistic regression: Individual covariates o Age younger than 65 o Personal Severity Index: Subset 1: Diagnoses Common Quality Agenda DRAFT - DO NOT CIRCULATE 30

31 Guidelines, SOPs, Evidence for best practice o More dependence in toileting o Resource Utilization Group (RUG) Cognitive Impairment Adjusted at facility level using direct standardization Case Mix Index N/A Comments Incidence indicators are calculated using two assessments in order to capture change from one quarter to the next. One assessment is from the fiscal quarter of interest ( target assessment) and the second assessment is from the previous quarter ( prior assessment). The general inclusion criteria for assessments to be included in the incidence indicators are: o o o o o Assessment was the latest assessment in the quarter Assessment was carried out more than 92 days from Admission Date Assessment was not an admission full assessment There was an assessment in the previous quarter There are days between the target and prior assessments Rolling four-quarter average: The indicator is evaluated every quarter and calculated based on the rolling average of the four previous fiscal quarters (12 months). This methodology is used because events are relatively rare in smaller facilities. Common Quality Agenda DRAFT - DO NOT CIRCULATE 31

32 Percent Current performance Figure1.Percent of CCC residents with new stage 2 or higher pressure ulcers in the last 3 months, Ontario, April to June 2010 January to March % Performance target = 1.6% 5.0% 0.0% Apr- Jun 2010 Jul- Sep 2010 Oct- Dec 2010 Jan- Mar 2011 Has a new stage 2 to 4 pressure ulcer 2.4% 2.4% 2.4% 2.3% 2.2% 2.1% 2.1% 2.2% 2.0% 2.2% 2.3% 2.3% Apr- Jun 2011 Jul- Sep 2011 Oct- Dec 2011 Jan- Mar 2012 Apr- Jun 2012 Jul- Sep 2012 Oct- Dec 2012 Jan- Mar 2013 Common Quality Agenda DRAFT - DO NOT CIRCULATE 32

33 Percent Figure2. Percent of CCC residents with new stage 2 or higher pressure ulcers in the last 3 months, Ontario, January to March 2013, by LHIN 10.0% Performance target = 1.6% 5.0% 0.0% ESC SW WW HNHB CW MH TC C CE SE CH NSM NE NW Has a new stage 2 to 4 pressure ulcer 5.4% 3.3% 1.7% 3.3% 2.4% 1.1% 1.1% 2.9% 4.0% 2.0% 1.4% 2.3% 3.1% 3.0% Statement of results The risk-adjusted percent of CCC residents with new stage 2 or higher pressure ulcers in the last 3 months was 2.3% between January and March, The rate has fluctuated between 2.0 and 2.5% since the first quarter of 2010 (see Figure1). There was wide variation in the rate of new pressure ulcer among CCC patients across LHINs. Based on the data from January to March, 2013, the LHIN specific rates ranged from1.1% in the Mississauga Halton LHIN to 5.4% in the Erie St. Clair LHIN (see Figure2). Common Quality Agenda DRAFT - DO NOT CIRCULATE 33

34 Percent of complex continuing care(ccc) residents who have fallen in the last 30 days Indicator This indicator measures the proportion of CCC patients who have fallen description in the previous 30 days. Relevance/ This is an important indicator because patients may experience serious Rationale consequences after a fall. It may lead to injuries and increase patients care needs and thus have negative impacts on the health care system. Reporting CIHI e-reporting tool to data submitters tool/product Attribute Safe Type Outcome and core indicator External QIP- Acute care sector Alignment Accountability Calculation Data source / data elements Timing and frequency of data release Levels of comparability Targets and/or Benchmarks Hospital Numerator Residents who had a fall in the last 30 days recorded on their target assessment Denominator CCC Residents with valid assessments The indicators are derived from RAI-MDS 2.0 through CIHI s Continuing Care Reporting System (CCRS), a reporting system that contains demographic, administrative and clinical information for residents from residential care and hospital-based continuing care facilities across Canada Data elements used: o J4a Fell in past 30 days CIHI reported the facility level quarterly data on e-reporting tool. Data submitters can access their data. HQO has access through data portal as well. Data updated by CIHI on e-reporting tool every quarter LHIN level and provincial data were available through data request Across time; by LHIN and facility (facility data are on CIHI portal; need CIHI permission for public reporting); QIP Benchmark: 5%; Ten percent relative decrease year over year. Target Source HQO benchmarking process (2012) + expert consultation Limitations While rolling four quarter averages stabilize the rates from quarter-toquarter variations, especially for smaller facilities, it is makes it more difficult to detect true quarterly improvements Adjustment (risk, age/sex standardization): Risk adjustment at two levels: Adjusted at individual resident level using logistic regression: Individual covariates o Age younger than 65 o Not totally dependent in transferring o Locomotion problem o Personal Severity Index: Subset 2: Non-Diagnoses o Any wandering o Unsteady gait/cognitive impairment Adjusted at facility level using direct standardization Stratification Case Mix Index Common Quality Agenda DRAFT - DO NOT CIRCULATE 34

35 Percent Guidelines, SOPs, Evidence for best practice Comments n/a Prevalence indicators are measured at one point in time and use a single assessment in their calculation. The general inclusion criteria for assessments to be included in the prevalence indicators are: o Assessment was the latest assessment in the quarter o o Assessment was carried out more than 92 days from admission date Assessment was not an admission full assessment Rolling four-quarter average: The indicator is evaluated every quarter and calculated based on the rolling average of the four previous fiscal quarters (12 months). This methodology is used because some events are relatively rare in smaller facilities. Current performance Figure1.Percent of CCC residents who had fallen in the past 30 days, Ontario, April to June 2010 January to March % Performance target = 5.0% Year over year relative reduction=10% 12.5% 0.0% Apr- Jun 2010 Jul-Sep 2010 Oct- Dec 2010 Jan- Mar 2011 Apr- Jun 2011 Jul-Sep 2011 Oct- Dec 2011 Jan- Mar 2012 Apr- Jun 2012 Jul-Sep 2012 Oct- Dec 2012 Jan- Mar 2013 Has fallen 9.7% 10.2% 10.3% 9.9% 9.3% 8.3% 8.4% 9.1% 9.4% 9.7% 9.9% 10.3% Common Quality Agenda DRAFT - DO NOT CIRCULATE 35

36 Percent Figure2. Percent of CCC residents who had fallen in the past 30 days, by LHIN, Ontario, January to March % Performance target = 5.0% Year over year relative reduction=10% 12.5% 0.0% ESC SW WW HNH CW MH TC C CE SE CH NSM NE NW B Risk Adjusted Percentage 8.6% 11.3% 6.8% 13.4% 7.6% 3.2% 7.3% 13.1% 8.6% 13.8% 4.5% 7.5% 11.0% 11.9% Statement of results The risk-adjusted percent of CCC residents who had fallen in the past 30 days was 10.3% between January and March, The rate has fluctuated over the past three years between 8.3% %. It increased slightly in the first three quarters of 2010/11, and then started decreasing. The lowest rate in the past three year was observed in July to September, 2011, and since then it has increased again (see Figure 1). There was wide LHIN-variation in the rate of falls among CCC residents. The LHIN specific rates ranged from 3.2% in the Mississauga Halton LHIN to 13.8% in the South East LHIN (see Figure2) during the period Jan-Mar, Common Quality Agenda DRAFT - DO NOT CIRCULATE 36

37 Percent of respondents who would definitely recommend the emergency department (ED) to family and friends Indicator description Survey question (NRC Picker): Would you recommend this ED to family and friends? - Yes, definitely - Yes, probably - No Better quality is associated with a higher score. The indicator is reported yearly in the QMonitor. Relevance/Rationale It is crucial to learn from patients perspective about the quality of services provided by hospitals. The NRC-picker survey helps the hospitals to measure and improve patient-centered care in ED. Reporting QMonitor; OHA/ NRC-Picker tool/product Attribute Patient-centered Type: Outcome and core indicator External Alignment QIP- acute care sector; OHA reporting; May also align with Health Links Accountability Hospital Calculation Numerator Number of survey respondents who choose Yes, definitely Denominator Number of survey respondents Data source / data NRC-Picker Survey, provided by OHA, available every fiscal elements year Timing and Fiscal year frequency of data release Levels of Across time; By hospital comparability Targets and/or QIP benchmark is 70.6%; Benchmarks Five percent year over year relative improvement Target source HQO benchmarking process (2012) + expert consultation Limitations Self-reported patient satisfaction; prone to survey related biases Adjustment (risk, Crude percent reported age/sex standardization): Guidelines, SOPs, N/A Evidence for best practice Common Quality Agenda DRAFT - DO NOT CIRCULATE 37

38 Percent Current performance Figure1. Percent of respondents who would definitely recommend this emergency department to family and friends in Ontario, FY2006/07- FY2011/ Performance target = 70.6% Year over year relative improvement = 5% / / / / / /12 ED Common Quality Agenda DRAFT - DO NOT CIRCULATE 38

39 Percent Figure2. Percent of respondents who would definitely recommend this emergency department to family and friends by hospital in Ontario, FY2010/ th percentile Median 90th percentile Performance target = 70.6% Year over year relative improvement = 5% 50 0 Hospital Table1. Facility-level distribution of percent of respondents who would definitely recommend this emergency department to family and friends in Ontario, FY2010/11 5 th 10 th 25 th Min Percentile Percentile Percentile Median Percentile Percentile Percentile Max th 90 th 95 th Statement of results In 2011/12, almost six in ten patients (59%) indicated that they would definitely recommend the ED in which they received care. This indicator has improved slightly, but significantly 5 since 2009/10. Among Ontario hospitals who had administered an NRC Picker Canada Acute Care Patient Experience Survey in 2010/11, there was wide variation in satisfaction rates ranging from 37% to 86% of patients who would recommend their hospital ED to friends and family. 5 Statistically significant differences are calculated at 95% confidence level and results are provided by OHA. Common Quality Agenda DRAFT - DO NOT CIRCULATE 39

40 Percent of respondents who would definitely recommend this hospital to family and friends (inpatient care) Indicator description Survey question: Would you recommend this hospital to family and friends? - Yes, definitely - Yes, probably - No Better quality is associated with a higher score. The indicator is reported yearly in the QMonitor. Relevance/Rationale It is crucial to learn from patients perspective about the quality of services provided by hospitals. The NRC-picker survey helps the hospitals to measure and improve patient-centered care in hospital. Reporting QMonitor; OHA/NRC-Picker tool/product Attribute Patient-centered Type: Outcome and core indicator External Alignment QIP- acute care sector; OHA reporting May also align with Health Links Accountability Hospital Calculation Numerator Number of survey respondents who choose Yes, definitely Denominator Number of survey respondents Data source / data NRC-Picker Survey, provided by OHA, available every fiscal elements year Timing and Fiscal yearly frequency of data release Levels of Across time; By hospital comparability Targets and/or QIP Benchmark is 81.8%; Benchmarks Five percent year over year relative improvement Target source HQO benchmarking process (2012) + expert consultation Limitations Self-reported patient satisfaction; prone to survey related biases Adjustment (risk, Crude percent reported age/sex standardization): Guidelines, SOPs, N/A Evidence for best practice Common Quality Agenda DRAFT - DO NOT CIRCULATE 40