2016-17 Hospital Service Accountability Agreement Indicator Technical Specifications October 2015
TABLE OF CONTENTS PATIENT EXPERIENCE ACCESS, EFFECTIVE, SAFE, PERSON-CENTERED... 5 PERFORMANCE... 5 90th Percentile Emergency Department (ED) length of stay for Complex Patients... 5 90th Percentile ED Length of Stay for Minor/Uncomplicated Patients... 8 Percent of Priority 2, 3 and 4 Cases Completed within Access Targets for Hip Replacements... 11 Percent of Priority 2, 3 and 4 Cases Completed within Access Targets for Knee Replacements... 14 Percent of Priority 2, 3 and 4 Cases Completed within Access Targets for MRI... 17 Percent of Priority 2, 3 and 4 Cases Completed within Access Targets for CT Scans... 20 Rate of Hospital Acquired Clostridium Difficile Infections... 23 EXPLANATORY... 26 Percent of Stroke/TIA Patients Admitted to a Stroke Unit During Their Inpatient Stay... 26 Hospital Standardized Mortality Ratio (HSMR)... 28 Rate of Ventilator-Associated Pneumonia... 32 Central Line Infection Rate... 34 Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus Bacteremia... 36 Percent of Priority 2, 3, and 4 cases completed within Access targets for Cardiac By-Pass Surgery... 38 Percent of Priority 2, 3, and 4 cases completed within Access targets for Cancer Surgery... 41 Percent of Priority 2, 3 and 4 Cases Completed within Access Targets for Cataract Surgery... 44 CLASSIFICATIONS TO BE DETERMINED... 47 Readmissions within 30 days for selected HBAM Inpatient Grouper (HIG) Conditions... 47 ORGANIZATIONAL HEALTH - EFFICIENT, APPROPRIATELY RESOURCED, EMPLOYEE EXPERIENCE, GOVERNANCE... 53 PERFORMANCE... 53 Current Ratio (Consolidated all sector codes and fund types)... 53 Total Margin (Consolidated all sector codes and fund types)... 56 EXPLANATORY... 59 Total Margin (Hospital Sector Only)... 59 Adjusted Working Funds / Total Revenue %... 62 SYSTEM PERSPECTIVE INTEGRATION, COMMUNITY ENGAGEMENT, EHEALTH... 65 PERFORMANCE... 65 Alternate Level of Care (ALC) Rate... 65 EXPLANATORY... 68 Percentage of Alternate Level of Care (ALC) Days... 68 2016/17 HSAA Technical Specifications Page 2
CLASSIFICATIONS TO BE DETERMINED... 70 Repeat Unscheduled Emergency Visits Within 30 Days for Mental Health Conditions... 70 Repeat Unscheduled Emergency Visits Within 30 Days for Substance Abuse Conditions... 73 APPENDIX: SERVICE VOLUME METRICS... 76 GLOBAL VOLUMES (SCHEDULE C2 PART I)... 76 Ambulatory Care Visits... 76 Complex Continuing Care Weighted Patient Days... 79 Day Surgery Weighted Visits... 81 Elderly Capital Assistance Program (ELDCAP) Inpatient Days... 83 ED Weighted Cases... 85 Emergency Department and Urgent Care Visits... 87 Inpatient Mental Health Weighted Days... 89 Inpatient Mental Health Days... 91 Inpatient Rehabilitation Days... 93 Rehabilitation Separations... 95 Total Inpatient Acute Weighted Cases... 97 HOSPITAL SPECIALIZED SERVICES (SCHEDULE C2 PART II)... 99 Cochlear Implants (Cases)... 99 Sexual Assault/Domestic Violence Treatment Clinics (Patients)... 102 WAIT TIME VOLUMES (SCHEDULE C2 PART III)... 105 General Surgery (Base & incremental)... 105 Paediatric Surgery (Base & incremental)... 108 Hip & Knee Replacement - Revisions (Cases)... 115 Magnetic Resonance Imaging (MRI) Total Hours... 118 Ontario Breast Screening Program (OBSP) Magnetic Resonance Imaging (MRI) Total Hours... 120 Computed Tomography (CT) Total Hours... 123 PROVINCIAL PROGRAMS (SCHEDULE C2 PART IV)... 125 Automatic Inplantable Cardiac Defib's (# of New Implants)... 125 Bariatric Surgery (Procedures)... 128 QUALITY BASED PROCEDURES (SCHEDULE C2 PART V)... 132 Congestive heart failure (CHF)... 132 Stroke - Hemorrhage... 134 Stroke Ischemic or Unspecified... 136 Stroke Transient Ischemic Attack (TIA)... 138 Non-Cardiac Vascular Aortic Aneurysm (AA)... 140 Non-Cardiac Vascular Lower Extremity Occlusive Disease (LEOD)... 142 Acute Primary Unilateral Hip Replacement... 144 Inpatient Rehab for Primary Unilateral Hip Replacement... 146 Acute Primary Unilateral Knee Replacement... 149 Inpatient Rehab for Primary Unilateral Knee Replacement... 151 Acute Primary Bilateral Joint Replacement (Hip/Knee)... 154 Inpatient Rehab Primary Bilateral Joint Replacement (Hip/Knee)... 156 2016/17 HSAA Technical Specifications Page 3
Hip Fracture... 159 Knee Arthroscopy... 161 Neonatal Jaundice (Hyperbilirubinemia)... 163 Tonsillectomy... 165 Chronic Obstructive Pulmonary Disease (COPD)... 167 Pneumonia... 169 Cataract... 171 Copyright 2015, Queens Printer, Ontario. All rights reserved. 2016/17 HSAA Technical Specifications Page 4
PATIENT EXPERIENCE Access, Effective, Safe, Person-Centered Performance INDICATOR NAME Detailed description of indicator INDICATOR CLASSIFICATION PERFORMANCE STANDARD 90TH PERCENTILE EMERGENCY DEPARTMENT (ED) LENGTH OF STAY FOR COMPLEX PATIENTS The total ED length of stay* where 9 out of 10 complex patients completed their visits. *ED Length of Stay defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED. Performance Target: (i) For hospitals performing at the provincial target or better: Performance target= maintain or improve current performance. Historical performance should be reviewed prior to target setting, and plans to maintain or improve the performance target are to be discussed. (ii) For hospitals performing below the provincial target: Performance target= provincial target or better. Historical performance should be reviewed prior to target setting, and plans to achieve the performance target are to be discussed. INDICATOR CALCULATION Corridor: Upper corridor = performance target + 10% Step 1: Calculate ED length of stay in hours for each patient. Step 2: Apply inclusion and exclusion criteria. Step 3: Sort the cases by ED length of stay from shortest to longest. Step 4: The 90th percentile is the case where 9 out of 10 complex patients have completed their visits. NACRS, Canadian Institute for Health Information (CIHI) via Ontario s ER NACRS Initiative (ERNI-Level 1). Inclusion Criteria: Admitted patients Disposition Codes 06 and 07 Non-Admitted Patients (Disposition Codes 01, 04 05 and 08 15) with assigned CTAS I, II, or III 2016/17 HSAA Technical Specifications Page 5
Exclusion Criteria: 1. ED visits where Registration Date/Time and Triage Date/Time are both blank/unknown (9999) 2. ED visits where the MIS functional centre is under Emergency Trauma, Observation or Emergency Mental Health Services (as of January 2015 data) 3. Duplicate cases within the same functional center where all ER data elements have the same values except for Abstract ID number 4. ED visits where the ED visit Indicator is = '0' 5. ED visits where patient has left without being seen by a physician during his/her visit (Disposition Code 02 and 03) 6. ED Length of Stay is greater than or equal to 100000 minutes (1666 hours) 7. Non-Admitted Patients (Disposition Codes 01 05 and 08 15) with assigned CTAS IV or V 8. Non-Admitted Patients (Disposition Codes 01 05 and 08 15) with missing CTAS TIMING/FREQUENCY OF RELEASE How often, and when, are data being released GEOGRAPHY & TIMING ADDITIONAL INFORMATION LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending LIMITATIONS Specific limitations COMMENTS Additional information regarding the calculation, interpretation, data source, etc. Access to Care at Cancer Care Ontario (CCO) has ongoing data quality improvement process in place for ER Level 1 NACRS. Timeliness and accuracy are key data quality dimensions that are monitored closely on a regular basis. Access to Care has developed a data quality matrix to assess the quality of ED data at three levels: Province, LHIN and facility. ED data in Ontario via CIHI-NACRS have been collected since July 2000. However, NACRS was modified to accept different reporting levels as of April 2009. The calculated 90th percentile ED length of stay at the provincial level, for the latest month can be compared with the baseline of April 2008 in the Emergency Room Wait Times Government of Ontario website and in the ED Reports provided to LHINs and hospitals every month (Provincial ER Highlights Report, ER LHIN Highlight Report, and the LHIN ER Pay for Results Report). Historical trend data from April 2008 onwards for all ED facilities in Ontario are available on request to ATCDataRequest@cancercare.on.ca. A small percentage of records are excluded from the analysis every month, due to missing/invalid values for the relevant wait time fields (such as Time patient left ED or Registration time etc.). Calculated indicator value is based on ED visits submitted by 126 sites participating in the ER National Ambulatory Care Reporting System (NACRS) Initiative (ERNI) reporting to the NACRS database. Approximately 90% of ED Visits in Ontario are captured by hospital sites participating in ERNI (based on NACRS 13/14 data released July 2014). As of April 2009, patient s stay in a designated Clinical Decision Unit (CDU) will be excluded in the total time spent in ED. 2016/17 HSAA Technical Specifications Page 6
Due to the introduction of newly designated CDUs in select hospitals, there may be a difference in the calculation methodology of the baseline and the quarterly indicators. Access to Care (ATC) Informatics regularly informs the LHINs of the CDU impact on the overall time spent in the Emergency Department through the monthly ED reports. LHINs are provided with the list of hospitals with designated CDUs. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, HTTP://... RESPONSIBILITY FOR REPORTING Cancer Care Ontario DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) 2015-10-15 2016/17 HSAA Technical Specifications Page 7
INDICATOR NAME Detailed description of indicator INDICATOR CLASSIFICATION PERFORMANCE STANDARD 90TH PERCENTILE ED LENGTH OF STAY FOR MINOR/UNCOMPLICATED PATIENTS The total ED length of stay* where 9 out of 10 minor/uncomplicated patients completed their visits. *ED Length of Stay defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED. Performance Target: (i) For hospitals performing at the provincial target or better: Performance target= maintain or improve current performance. Historical performance should be reviewed prior to target setting, and plans to maintain or improve the performance target are to be discussed. (ii) For hospitals performing below the provincial target: Performance target= provincial target or better. Historical performance should be reviewed prior to target setting, and plans to achieve the performance target are to be discussed. CALCULATION Corridor: Upper corridor = performance target + 10% Step 1: Calculate ED length of stay in hours for each patient. Step 2: Apply Inclusion and Exclusion Criteria. Step 3: Sort the cases by ED length of stay from shortest to highest. Step 4: The 90th percentile is the case where 9 out of 10 minor/uncomplicated patients have completed their visits. NACRS, CIHI via Ontario s ER NACRS Initiative (ERNI-Level 1). INDICATOR Inclusion Criteria: Non-Admitted Patients Disposition Codes 01, 04 05 and 08 15 with assigned CTAS IV and V. Exclusion Criteria: 1. ED visits where Registration Date/Time and Triage Date/Time are both blank/unknown (9999) 2. ED visits where the MIS functional centre is under Emergency Trauma, Observation or Emergency Mental Health Services (as of January 2015 data) 2016/17 HSAA Technical Specifications Page 8
TIMING/FREQUENCY OF RELEASE How often, and when, are data being released 3. Duplicate cases within the same functional center where all ER data elements have the same values except for Abstract ID number 4. ED visits where the ED visit Indicator is = '0' 5. ED visits where patient has left without being seen by a physician during his/her visit (Disposition Code 02 & 03) 6. ED Length of Stay is greater than or equal to 100000 minutes (1666 hours) 7. Admitted Patients (Disposition Codes 06 and 07) 8. Non-Admitted Patients (Disposition Codes 01, 04 05 and 08 15) with assigned CTAS I, II and II 9. Non-Admitted Patients (Disposition Codes 01, 04 05 and 08 15) with missing CTAS GEOGRAPHY & TIMING ADDITIONAL INFORMATION LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending LIMITATIONS Specific limitations COMMENTS Additional information regarding the calculation, interpretation, data source, etc. Access to Care at CCO has ongoing data quality improvement process in place for ER Level 1 NACRS. Timeliness and accuracy are key data quality dimensions that are monitored closely on a regular basis. Access to Care has developed a data quality matrix to assess the quality of ED data at three levels: Province, LHIN and facility. ED data in Ontario via CIHI-NACRS have been collected since July 2000. However, NACRS was modified to accept different reporting levels as of April 2009. The calculated 90th percentile ED LOS at the provincial level, for the latest month can be compared with the baseline of April 2008 in the Emergency Room Wait Times Government of Ontario website and in the ED Reports provided to LHIN s and hospitals every month (Provincial ER Highlights Report, ER LHIN Highlight Report, and the LHIN ER Pay for Results Report). Historical trend data from April 2008 onwards for all ED facilities in Ontario are available on request to ATCDataRequest@cancercare.on.ca. A small percentage of records are excluded from the analysis every month, due to missing/invalid values for the relevant wait time fields (such as Time patient left ED or Registration time etc.). Calculated indicator value is based on ED visits submitted by 126 sites participating in the ER NACRS Initiative ERNI reporting to the NACRS database. Approximately 90% of ED Visits in Ontario are captured by hospital sites participating in ERNI (based on NACRS 13/14 data released July 2014). As of April 2009, patient s stay in a designated CDU will be excluded in the total time spent in ER. Due to the introduction of newly designated CDUs in select hospitals, there may be a difference in the calculation methodology of the baseline and the quarterly indicators. ATC Informatics regularly informs the LHINs of the CDU 2016/17 HSAA Technical Specifications Page 9
impact on the overall time spent in the ED through the monthly ED reports. LHINs are provided with the list of hospitals with designated CDUs. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, HTTP://... RESPONSIBILITY FOR REPORTING Cancer Care Ontario DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) 2015-10-15 2016/17 HSAA Technical Specifications Page 10
INDICATOR NAME Detailed description of indicator PERCENT OF PRIORITY 2, 3 AND 4 CASES COMPLETED WITHIN ACCESS TARGETS FOR HIP REPLACEMENTS Descriptions of priority levels can be found in the link within the Reference section. INDICATOR CLASSIFICATION PERFORMANCE STANDARD Performance Target: (i) For hospitals performing at the provincial target or better: Performance target = maintain or improve current performance. Historical performance should be reviewed prior to target setting, and plans to maintain or improve the performance target are to be discussed. (ii) For hospitals performing below provincial target: Performance target= provincial target or better. Historical performance should be reviewed prior to target setting, and plans to achieve the performance target are to be discussed. INDICATOR CALCULATION Corridor: Greater than or equal to the performance target to 100%. Step 1: Count the total number of cases completed for the reporting period by priority level (Priority 2, 3 and 4). Please refer to the inclusion/exclusion criteria listed below. Step 2: Of the total count in step 1, count the number of cases where wait times are less than or equal to the provincial targets. Do this for all of the three priority levels (Priority 2, 3, and 4). Step 3: The weighted percent of cases completed within Priority 2, 3 and 4 access targets = sum of the counts by Priority in step 2 divided by the sum of the counts by Priority in step 1 x 100 to get the percentage. Sample calculation: WTIS, ATC, Cancer Care Ontario. 2016/17 HSAA Technical Specifications Page 11
GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending Access to Care has implemented a robust data quality and compliance framework to assess data quality under four key dimensions: timeliness, validity, reliability and usability. The complete framework is available in the Wait Time Conditions of Funding and further information is available upon request at: ATCsupport@cancercare.on.ca. All closed wait list entries with procedure dates within date range submitted by hospitals through the WTIS. Patient age greater than or equal to 18 years old on the day the procedure was completed. Procedures no longer required (or cancelled cases) are excluded from wait time calculation. Procedures assigned as priority level 1 cases are excluded from wait time calculation. Cases with missing priority levels are also excluded. Wait list entries identified by hospitals as data entry errors are excluded. If unavailable days fall outside the decision to treat date up to procedure date, unavailable days are not deducted from patients wait days. These are considered data entry errors. As part of ATC s on-going data quality and compliance processes with hospitals, accuracy is one of the key areas that have been monitored closely over time and assessed on a regular basis along with other data quality dimensions. ATC monitors data quality with hospitals on a weekly basis and works closely with hospitals WTIS coordinators to ensure data quality indicators and thresholds are met. If hospitals have challenges meeting data quality thresholds they may be excluded from wait time reporting calculations as well as public reporting. In these circumstances hospital, LHIN and/or ministry leadership is engaged to ensure hospital data quality is enhanced to become reportable as soon as possible. The calculated percent of cases completed within priority target can be compared with the historical trend published in the Government of Ontario wait time s website. All inclusions/exclusions criteria used are similar. Also, historical wait times trend for low volume hospitals/lhins will show as NV (no or low volume) instead of a calculated percent of cases completed within priority target. ADDITIONAL INFORMATION LIMITATIONS Specific limitations COMMENTS Additional information regarding the calculation, Hospitals submitting wait time data voluntarily (not required to report) are included in wait time calculation. Calculated percent of cases completed within priority targets is based only on the number of cases entered in the system. Logically, hospitals not reporting cases promptly are excluded at the 2016/17 HSAA Technical Specifications Page 12
interpretation, data source, etc. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, HTTP://... RESPONSIBILITY FOR REPORTING time of data extraction. Volumes submitted by hospitals are checked monthly for completeness. Hospital volume is compared against the expected monthly average. Outliers are validated with hospitals if the wait days are not accurate. http://www.health.gov.on.ca/en/pro/programs/waittimes/surgery/target.as px Cancer Care Ontario DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) 2015-10-15 2016/17 HSAA Technical Specifications Page 13
INDICATOR NAME Detailed description of indicator PERCENT OF PRIORITY 2, 3 AND 4 CASES COMPLETED WITHIN ACCESS TARGETS FOR KNEE REPLACEMENTS Descriptions of priority levels can be found in the link within the Reference section. INDICATOR CLASSIFICATION PERFORMANCE STANDARD Performance Target: (i) For hospitals performing at the provincial target or better: Performance target = maintain or improve current performance. Historical performance should be reviewed prior to target setting, and plans to maintain or improve the performance target are to be discussed. (ii) For hospitals performing below provincial target: Performance target= provincial target or better. Historical performance should be reviewed prior to target setting, and plans to achieve the performance target are to be discussed. INDICATOR CALCULATION Corridor: Greater than or equal to the performance target to 100%. Step 1: Count the total number of cases completed for the reporting period by priority level (Priority 2, 3 and 4). Please refer to the inclusion/exclusion criteria listed below. Step 2: Of the total count in step 1, count the number of cases where wait times are less than or equal to the provincial targets. Do this for all of the three priority levels (Priority 2, 3, and 4). Step 3: The weighted percent of cases completed within Priority 2, 3 and 4 access targets = sum of the counts by Priority in step 2 divided by the sum of the counts by Priority in step 1 x 100 to get the percentage. Sample calculation: WTIS, ATC, Cancer Care Ontario. 2016/17 HSAA Technical Specifications Page 14
Access to Care has implemented a robust data quality and compliance framework to assess data quality under four key dimensions: timeliness, validity, reliability and usability. The complete framework is available in the Wait Time Conditions of Funding and further information is available upon request at: ATCsupport@cancercare.on.ca. All closed wait list entries with procedure dates within date range submitted by hospitals through the WTIS. Patient age greater than or equal to 18 years old on the day the procedure was completed. Procedures no longer required (or cancelled cases) are excluded from wait time calculation. Procedures assigned as priority level 1 cases are excluded from wait time calculation. Cases with missing priority levels are also excluded. Wait list entries identified by hospitals as data entry errors are excluded. If unavailable days fall outside the decision to treat date up to procedure date, unavailable days are not deducted from patients wait days. These are considered data entry errors. TIMING/FREQUENCY OF RELEASE How often, and when, are data being released GEOGRAPHY & TIMING ADDITIONAL INFORMATION LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending LIMITATIONS Specific limitations COMMENTS Additional information regarding the calculation, As part of ATC s on-going data quality and compliance processes with hospitals, accuracy is one of the key areas that have been monitored closely over time and assessed on a regular basis along with other data quality dimensions. ATC monitors data quality with hospitals on a weekly basis and works closely with hospitals WTIS coordinators to ensure data quality indicators and thresholds are met. If hospitals have challenges meeting data quality thresholds they may be excluded from wait time reporting calculations as well as public reporting. In these circumstances hospital, LHIN and/or ministry leadership is engaged to ensure hospital data quality is enhanced to become reportable as soon as possible. The calculated percent of cases completed within priority target can be compared with the historical trend published in the Government of Ontario wait time s website. All inclusions/exclusions criteria used are similar. Also, historical wait times trend for low volume hospitals/lhins will show as NV (no or low volume) instead of a calculated percent of cases completed within priority target. Hospitals submitting wait time data voluntarily (not required to report) are included in wait time calculation. Calculated percent of cases completed within priority targets is based only on the number of cases entered in the 2016/17 HSAA Technical Specifications Page 15
interpretation, data source, etc. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, HTTP://... RESPONSIBILITY FOR REPORTING system. Logically, hospitals not reporting cases promptly are excluded at the time of data extraction. Volumes submitted by hospitals are checked monthly for completeness. Hospital volume is compared against the expected monthly average. Outliers are validated with hospitals if the wait days are not accurate. http://www.health.gov.on.ca/en/pro/programs/waittimes/surgery/target.as px Cancer Care Ontario DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) 2015-10-15 2016/17 HSAA Technical Specifications Page 16
INDICATOR NAME Detailed description of indicator PERCENT OF PRIORITY 2, 3 AND 4 CASES COMPLETED WITHIN ACCESS TARGETS FOR MRI Descriptions of priority levels can be found in the link within the Reference section. INDICATOR CLASSIFICATION PERFORMANCE STANDARD Performance Target: (i) For hospitals performing at the provincial target or better: Performance target = maintain or improve current performance. Historical performance should be reviewed prior to target setting, and plans to maintain or improve the performance target are to be discussed. (ii) For hospitals performing below provincial target: Performance target= provincial target or better. Historical performance should be reviewed prior to target setting, and plans to achieve the performance target are to be discussed. INDICATOR CALCULATION Corridor: Greater than or equal to the performance target to 100%. Step 1: Count the total number of cases completed for the reporting period by priority level (Priority 2, 3 and 4). Please refer to the inclusion/exclusion criteria listed below. Step 2: Of the total count in step 1, count the number of cases where wait times are less than or equal to the provincial targets. Do this for all of the three priority levels (Priority 2, 3, and 4). Step 3: The weighted percent of cases completed within Priority 2, 3 and 4 access targets = sum of the counts by Priority in step 2 divided by the sum of the counts by Priority in step 1 x 100 to get the percentage. Sample calculation: 2016/17 HSAA Technical Specifications Page 17
Wait Time Information System (WTIS), Access to Care (ATC), Cancer Care Ontario. GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending Access to Care has implemented a robust data quality and compliance framework to assess data quality under four key dimensions: timeliness, validity, reliability and usability. The complete framework is available in the Wait Time Conditions of Funding and further information is available upon request at: ATCsupport@cancercare.on.ca. All closed wait list entries with procedure dates within date range submitted by hospitals through the Wait Time Information System. Patient age greater than or equal to 18 years old on the day the procedure was completed. Procedures no longer required (or cancelled cases) are excluded from wait time calculation. Procedures assigned as priority level 1 cases are excluded from wait time calculation. Cases with missing priority levels are also excluded. Wait list entries identified by hospitals as data entry errors are excluded. If unavailable days fall outside the decision to treat date up to procedure date, unavailable days are not deducted from patients wait days. These are considered data entry errors. Diagnostic Imaging (DI) cases classified as specified date procedures (timed procedures) are excluded from wait time calculation. As part of ATC s on-going data quality and compliance processes with hospitals, accuracy is one of the key areas that have been monitored closely over time and assessed on a regular basis along with other data quality dimensions. ATC monitors data quality with hospitals on a weekly basis and works closely with hospitals WTIS coordinators to ensure data quality indicators and thresholds are met. If hospitals have challenges meeting data quality thresholds they may be excluded from wait time reporting calculations as well as public reporting. In these circumstances hospital, LHIN and/or ministry leadership is engaged to ensure hospital data quality is enhanced to become reportable as soon as possible. The calculated percent of cases completed within priority target can be compared with the historical trend published in the Government of Ontario wait time s website. All inclusions/exclusions criteria used are similar. Also, historical wait times trend for low volume hospitals/lhins will show as NV (no or low volume) instead of a calculated percent of cases completed within priority target. 2016/17 HSAA Technical Specifications Page 18
ADDITIONAL INFORMATION LIMITATIONS Specific limitations COMMENTS Additional information regarding the calculation, interpretation, data source, etc. Hospitals submitting wait time data voluntarily (not required to report) are included in wait time calculation. Calculated percent of cases completed within priority targets is based only on the number of cases entered in the system. Logically, hospitals not reporting cases promptly are excluded at the time of data extraction. Volumes submitted by hospitals are checked monthly for completeness. Hospital volume is compared against the expected monthly average. Outliers are validated with hospitals if the wait days are not accurate. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, HTTP://... RESPONSIBILITY FOR REPORTING DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) http://www.health.gov.on.ca/en/pro/programs/waittimes/surgery/target.as px Cancer Care Ontario 2015-10-15 2016/17 HSAA Technical Specifications Page 19
INDICATOR NAME PERCENT OF PRIORITY 2, 3 AND 4 CASES COMPLETED WITHIN ACCESS TARGETS FOR CT SCANS Detailed description of indicator Descriptions of priority levels can be found in the link within the Reference section. INDICATOR CLASSIFICATION Performance Target: (i) For hospitals performing at the provincial target or better: Performance target = maintain or improve current performance. Historical performance should be reviewed prior to target setting, and plans to maintain or improve the performance target are to be discussed. PERFORMANCE STANDARD (ii) For hospitals performing below provincial target: Performance target= provincial target or better. Historical performance should be reviewed prior to target setting, and plans to achieve the performance target are to be discussed. INDICATOR CALCULATION Corridor: Greater than or equal to the performance target to 100%. Step 1: Count the total number of cases completed for the reporting period by priority level (Priority 2, 3 and 4). Please refer to the inclusion/exclusion criteria listed below. Step 2: Of the total count in step 1, count the number of cases where wait times are less than or equal to the provincial targets. Do this for all of the three priority levels (Priority 2, 3, and 4). Step 3: The weighted percent of cases completed within Priority 2, 3 and 4 access targets = sum of the counts by Priority in step 2 divided by the sum of the counts by Priority in step 1 x 100 to get the percentage. Sample calculation: 2016/17 HSAA Technical Specifications Page 20
Wait Time Information System (WTIS), Access to Care (ATC), Cancer Care Ontario. Access to Care has implemented a robust data quality and compliance framework to assess data quality under four key dimensions: timeliness, validity, reliability and usability. The complete framework is available in the Wait Time Conditions of Funding and further information is available upon request at: ATCsupport@cancercare.on.ca. All closed wait list entries with procedure dates within date range submitted by hospitals through the Wait Time Information System. Patient age greater than or equal to 18 years old on the day the procedure was completed. Procedures no longer required (or cancelled cases) are excluded from wait time calculation. Procedures assigned as priority level 1 cases are excluded from wait time calculation. Cases with missing priority levels are also excluded. Wait list entries identified by hospitals as data entry errors are excluded. If unavailable days fall outside the decision to treat date up to procedure date, unavailable days are not deducted from patients wait days. These are considered data entry errors. Diagnostic Imaging (DI) cases classified as specified date procedures (timed procedures) are excluded from wait time calculation. TIMING/FREQUENCY OF RELEASE How often, and when, are data being released GEOGRAPHY & TIMING LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending As part of ATC s on-going data quality and compliance processes with hospitals, accuracy is one of the key areas that have been monitored closely over time and assessed on a regular basis along with other data quality dimensions. ATC monitors data quality with hospitals on a weekly basis and works closely with hospitals WTIS coordinators to ensure data quality indicators and thresholds are met. If hospitals have challenges meeting data quality thresholds they may be excluded from wait time reporting calculations as well as public reporting. In these circumstances hospital, LHIN and/or ministry leadership is engaged to ensure hospital data quality is enhanced to become reportable as soon as possible. The calculated percent of cases completed within priority target can be compared with the historical trend published in the Government of Ontario wait time s website. All inclusions/exclusions criteria used are similar. Also, historical wait times trend for low volume hospitals/lhins will show as NV 2016/17 HSAA Technical Specifications Page 21
(no or low volume) instead of a calculated percent of cases completed within priority target. ADDITIONAL INFORMATION LIMITATIONS Specific limitations COMMENTS Additional information regarding the calculation, interpretation, data source, etc. Hospitals submitting wait time data voluntarily (not required to report) are included in wait time calculation. Calculated percent of cases completed within priority targets is based only on the number of cases entered in the system. Logically, hospitals not reporting cases promptly are excluded at the time of data extraction. Volumes submitted by hospitals are checked monthly for completeness. Hospital volume is compared against the expected monthly average. Outliers are validated with hospitals if the wait days are not accurate. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, HTTP://... RESPONSIBILITY FOR REPORTING DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) http://www.health.gov.on.ca/en/pro/programs/waittimes/surgery/target.as px Cancer Care Ontario 2015-10-15 2016/17 HSAA Technical Specifications Page 22
INDICATOR NAME RATE OF HOSPITAL ACQUIRED CLOSTRIDIUM DIFFICILE INFECTIONS Detailed description of indicator INDICATOR CLASSIFICATION PERFORMANCE STANDARD The rate of hospital acquired Clostridium difficile infections (CDI) is a measure of the incidence of disease and is the number of CDI cases per 1,000 patient days. Performance Target: 0 or hospital Quality Improvement Plan (QIP) target Corridor: Upper corridor = 10% improvement on current rate or the submitted Health Quality Ontario QIP target, whichever is greater LHINs and hospitals should review current rates and identify achievable performance improvement or maintenance of current performance levels CALCULATION The total number of new nosocomial (i.e. hospital acquired) CDI cases in the reporting period multiplied by 1,000 Self Reporting Initiative (SRI), Ontario Ministry of Health and Long-Term Care (MOHLTC) NUMERATOR Includes: 1. All publicly funded hospitals 2. Inpatient beds 3. Laboratory-confirmed CDI cases (i.e. confirmation of a positive toxin assay (A/B) for Clostridium difficile together with diarrhea OR visualization of pseudomembranes on sigmoidoscopy or colonoscopy, or histological/pathological diagnosis of pseudomembranous colitis) 4. New nosocomial cases associated with the reporting facility is where the infection was not present on admission (i.e., onset of symptoms > 72 hours after admission) or the infection was present at the time of admission but was related to a previous admission to the same facility within the last 4 weeks and the case has not had CDI in the past 8 weeks. Excludes: 1. Patients less than 1 year of age 2. Long-term care beds 2016/17 HSAA Technical Specifications Page 23
CALCULATION The total number of patient days spent in-hospital in a reporting period DENOMINATOR Self Reporting Initiative (SRI), Ontario Ministry of Health and Long-Term Care (MOHLTC) Includes: 1. All publicly funded hospitals 2. Inpatient beds Excludes: 1. Patients less than 1 year of age 2. Long-term care beds GEOGRAPHY & TIMING ADDITIONAL INFORMATION TIMING/FREQUENCY OF RELEASE How often, and when, are data being released E.g. Be as specific as possible..data are released annually in mid- May LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending LIMITATIONS Specific limitations COMMENTS Additional information regarding the calculation, interpretation, data source, etc. Data are available each month for the previous month s data. Data may be aggregated across reporting periods to generate more stable rates. Data are available at provincial, LHIN and hospital levels Data are available from September 2008 Data are self-reported by hospital No individual patient data are available, therefore indicator cannot be broken down by age, gender, income or education Baseline data should be generated on 1-years worth of data since CDI is expected to fluctuate seasonally Trending and comparisons are most valid by hospital type (e.g. small, large community, acute teaching, chronic care and rehab and mental health). This is in order to make limited adjustment for patient case mix. The CDI rate calculation allows the level of hospital activity to be taken into account because this will fluctuate over time and is different across hospitals. Hospital rates can also fluctuate significantly from one reporting 2016/17 HSAA Technical Specifications Page 24
period to another for a variety of reasons. For example, a small hospital with relatively few patient days when compared to larger institutions could see its rates vary dramatically based on one or two cases in any given month. These types of fluctuations will level out over a longer period of time. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, HTTP://... RESPONSIBILITY FOR REPORTING Patient Safety Website Health Service Providers DATE CREATED (YYYY- MM-DD) 2009-10-13 DATE LAST REVIEWED (YYYY-MM-DD) 2013-01-13 2016/17 HSAA Technical Specifications Page 25
Explanatory INDICATOR NAME Detailed description of indicator INDICATOR CLASSIFICATION PERCENT OF STROKE/TIA PATIENTS ADMITTED TO A STROKE UNIT DURING THEIR INPATIENT STAY All stroke/tia patients should be admitted to a stroke unit for acute stroke management for improved outcomes Explanatory Stroke/TIA Patients (Most Responsible Diagnosis = I60, I61, I63, I64, G45, H34.0, H34.1) admitted to a Stroke unit at any point during their inpatient stay, multiplied by 100 NUMERATOR CALCULATION A stroke unit is a geographical unit with identifiable co-located beds (e.g., 5A-7, 5A-8, 5A-9) that are occupied by stroke patients 75% of the time and has a dedicated interprofessional team with expertise in stroke care including, at a minimum, nursing, physiotherapy, occupational therapy and speech-language pathology. Ontario Stroke Registry, Ontario Stroke Audit Hospitals participating in CIHI Special Project #340 via the Discharge Abstract Database (DAD), Canadian Institute for Health Information (CIHI) Excludes: 1. Diagnostic code G45.4, I63.6, I60.8 CALCULATION Stroke/TIA Patients (Most Responsible Diagnosis = I60, I61, I63, I64, G45, H34.0, H34.1) admitted Ontario Stroke Registry, Ontario Stroke Audit DENOMINATOR Hospitals participating in CIHI Special Project #340 via the DAD, CIHI Excludes: 1. Diagnostic code excludes I63.6, I60.8, G45.4 2. Patients with palliative measures as part of the initial treatment plan. 3. OSA: In-hospital strokes 4. OSA 2012/13 excludes Subarachnoid hemorrhages. Includes adult patients only (18 and over) 2016/17 HSAA Technical Specifications Page 26
GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released E.g. Be as specific as possible..data are released annually in mid- May LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending Data are available from Ontario Stroke Audit Data are available annually in December for all hospitals beginning in 2012/13. Data are available at the level of the facility LHIN Data are available as of 2004 LIMITATIONS Specific limitations There may be limitations as a result of the DAD being the only data source ADDITIONAL INFORMATION COMMENTS Additional information regarding the calculation, interpretation, data source, etc. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, HTTP://... RESPONSIBILITY FOR REPORTING The Ontario Stroke Network s Ontario Stroke Report Cards report stroke unit at a population level. Analysis is based on a patient s postal code, not facility. 1. Canadian Best Practices SU section (http://www.strokebestpractices.ca/index.php/acute-strokemanagement/stroke-unit-care-2/) 2. QBP Handbook (http://www.hqontario.ca/portals/0/documents/eds/clinicalhandbooks/community-stroke-20151802-en.pdf page 91) 3. Ontario Stroke Report Cards, indicator 8 (http://www.ices.on.ca/publications/atlases-and-reports/2015/ontario- Stroke-Report-Cards) ICES DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) 2010-08-01 2015-10-15 2016/17 HSAA Technical Specifications Page 27
INDICATOR NAME HOSPITAL STANDARDIZED MORTALITY RATIO (HSMR) The hospital standardized mortality ratio (HSMR) is a big-dot summary measure that is used to track a hospital s mortality over time. The HSMR is a tool that allows hospitals to measure and monitor their progress in quality of care. HSMR is a ratio of the actual number of in-hospital deaths in a region or hospital to the number that would have been expected based on the types of patients a region or hospital treats. It focuses on the diagnosis groups that account for the majority of in-hospital deaths. Detailed description of indicator Observed deaths HSMR= x 100 Expected deaths Using a logistic regression model, HSMR is adjusted for several factors that affect in-hospital mortality, including age, sex, length of stay, admission category, diagnosis group, co morbidity and transfer from another acute care institution. A ratio equal to 100 suggests that there is no difference between a local mortality rate and the average national experience, given the types of patients cared for. An HSMR greater or less than 100 suggests that a local mortality rate is higher or lower, respectively, than the national experience. The confidence intervals describe the precision of the HSMR estimate. HSMR values are estimated to be accurate within the upper and lower confidence interval, 19 times out of 20. 95% confidence interval is calculated using Byar s approximation. A confidence interval that includes 100 suggests that the HSMR is not statistically different from the 2004 2005 baseline of 100. HSMR results whose confidence interval does not include 100 are statistically different from the baseline. INDICATOR CLASSIFICATION Explanatory NUMERATOR CALCULATION Observed deaths, or actual number of in-hospital deaths that occurred in a hospital or region (among patients who satisfy HSMR inclusion and exclusion criteria). Discharge Abstract Database (DAD), Canadian Institute of Health Information (CIHI) 2016/17 HSAA Technical Specifications Page 28
Inclusion criteria: 1. Discharge between April 1 of a given year and March 31 of the following year 2. Admission to an acute care institution 3. Discharge with diagnosis group of interest (that is, one of the diagnosis groups that account for approximately 80% of in-hospital deaths) 4. Age at admission between 0 and 120 years 5. Sex recorded as male or female 6. Length of stay of up to 365 consecutive days 7. Admission category is elective or emergent/urgent 8. Canadian resident Exclusion criteria: 1. Cadavers 2. Stillborns 3. Sign-outs (that is, discharged against medical advice) 4. Patients who do not return from a pass 5. Neonates, with age at admission less than or equal to 28 days 6. Records with brain death as most responsible diagnosis code 7. Records with palliative care as most responsible diagnosis code Expected deaths, or number of deaths that would have occurred in a hospital or region had the mortality of these patients been the same as the mortality of similar patients across the country, based on the reference year (2004 2005). DENOMINATOR CALCULATION The HSMR logistic regression model is fitted with age, sex, length-of-stay (LOS) group, admission category, diagnosis group, co morbidity group and transfers as independent variables and is based on data from all acute hospitals in Canada (excluding Quebec). Coefficients derived from a logistic regression model are used to calculate the probability of inhospital death. The expected number of deaths for a hospital, corporation or region is based on the sum of the probabilities of inhospital death for eligible discharges from that organization. DAD, CIHI Includes: 1. Discharge between April 1 of a given year and March 31 of the following year 2. Admission to an acute care institution 3. Discharge with diagnosis group of interest (that is, one of the diagnosis groups that account for approximately 80% of in-hospital deaths) 4. Age at admission between 0 and 120 years 5. Sex recorded as male or female 6. Length of stay of up to 365 consecutive days 7. Admission category is elective or emergent/urgent 8. Canadian resident 2016/17 HSAA Technical Specifications Page 29
Excludes: 1. Cadavers 2. Stillborns 3. Sign-outs 4. Patients who did not return from a pass 5. Neonates, with age at admission less than or equal to 28 days 6. Records with brain death as most responsible diagnosis code 7. Records with palliative care as most responsible diagnosis GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released E.g. Be as specific as possible..data are released annually in mid- May LEVELS OF COMPARABILITY Levels of geography for comparison Results are available on a quarterly (Q1 and Q2 in February, Q3 in May and Q4 in September) and annual (in September, together with Q4 reports) basis. Results are available for hospitals or hospital corporations (where applicable) and Local Health Integration Networks (LHINs). TRENDING Years available for trending LIMITATIONS Specific limitations FY 2004-2005 till present Currently no information has been provided. ADDITIONAL INFORMATION COMMENTS Additional information regarding the calculation, interpretation, data source, etc. REFERENCES The reference year for HSMR calculations is 2004 2005. To allow for comparisons over time, the coefficients derived from the model using the reference year are used to determine expected deaths for all reported years. While HSMR adjusts for a number of factors affecting the risk of in-hospital mortality, it does not control for every factor. Therefore, HSMR results are most useful in tracking trends over time. More information about HSMR calculation can be found at the Methodology section of HSMR web-page. 1. HSMR web-page Provide URLs of any key references E.g. Diabetes in Canada, HTTP://... 2. Canadian Institute for Health Information. HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada. Ottawa, Ont.: CIHI, 2007. 2016/17 HSAA Technical Specifications Page 30
3. Jarman, B., A. Bottle and P. Aylin. Monitoring Changes in Hospital Standardised Mortality Ratios. BMJ 330 (2005): p. 329. 4. Breslow, N. E. and N. E. Day. Statistical Methods in Cancer Research: Volume II The Design and Analysis of Cohort Studies. Lyon, France: International Agency for Research on Cancer, 1987. 5. Quan, H., V. Sundararajan, P. Halfon, A. Fong, B. Burnand, J. C. Luthi, L. D. Saunders, C. A. Beck, T. E. Feasby and W. A. Ghali. Coding Algorithms for Defining Comorbidities in ICD-9-CM and ICD-10 Administrative Data. Medical Care 43, 11 (2005): pp. 1130 1139. RESPONSIBILITY FOR REPORTING CIHI DATE CREATED (YYYY- MM-DD) 2010-12-15 DATE LAST REVIEWED (YYYY-MM-DD) 2011-02-03 2016/17 HSAA Technical Specifications Page 31
INDICATOR NAME RATE OF VENTILATOR-ASSOCIATED PNEUMONIA INDICATOR DESCRIPTION Detailed description of indicator INDICATOR CLASSIFICATION Pneumonia occurring in patients requiring mechanical ventilation, intermittently or continuously, through a tracheostomy or endotracheal tube for more than 48 hours Explanatory CALCULATION Total number of VAP cases age 18 and older that have required at least 48 hours of mechanical ventilation during the reporting period NUMERATOR Critical Care Information System (CCIS), Ontario Ministry of Health and Long- Term Care (MOHLTC) Includes: 1. All publicly funded hospitals 2. ICU beds 3. Patients diagnosed with VAP and being treated with antibiotics for VAP CALCULATION Excludes: 1. Patients age 17 and younger Total number of ventilator days for Intensive Care Unit (ICU) patients age 18 and older during the reporting period DENOMINATOR Critical Care Information System (CCIS), Ontario Ministry of Health and Long- Term Care (MOHLTC) Includes: 1. All publicly funded hospitals 2. ICU beds Excludes: 1. Patients age 17 and younger GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released E.g. Be as specific as possible..data are Data are available each quarter for the previous quarter s data 2016/17 HSAA Technical Specifications Page 32
released annually in mid- May LEVELS OF COMPARABILITY Levels of geography for comparison Data are available at provincial, LHIN and hospital levels TRENDING Years available for trending LIMITATIONS Specific limitations Data are available for the previous quarter as of April 2009 Data are self-reported by hospital. No individual patient data are available; therefore this indicator cannot be broken down by socio-demographic characteristics. ADDITIONAL INFORMATION COMMENTS Additional information regarding the calculation, interpretation, data source, etc. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, HTTP://... Trending and comparisons are most valid by hospital type (e.g. small, large community, acute teaching, chronic care and rehab and mental health). This is in order to make limited adjustment for patient case mix. Patient Safety Website RESPONSBILITY FOR REPORTING Health Service Providers DATE CREATED (YYYY- MM-DD) 2009-10-13 DATE LAST REVIEWED (YYYY-MM-DD) 2013-01-13 2016/17 HSAA Technical Specifications Page 33
INDICATOR NAME PROGRAM SPECIFIC INDICATOR NAME(S) How the indicator is named by specific programs Detailed description of indicator INDICATOR CLASSIFICATION CENTRAL LINE INFECTION RATE Central Line-Associated Primary Bloodstream Infection (CLI) Rate Number of intensive care unit (ICU) patients with new central line bloodstream infection (BSI)(CLI) per 1,000 central line days Explanatory CALCULATION Total number of laboratory confirmed BSI developing in patients age 18 and older in the ICU after 48 hours of placement of a central line NUMERATOR DENOMINATOR GEOGRAPHY & TIMING CALCULATION TIMING/FREQUENCY OF RELEASE How often, and when, are data being released E.g. Be as specific as possible..data are released annually in mid- May LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending Critical Care Information System (CCIS), Ministry of Health and Long-Term Care (MOHLTC) Includes: 1. Patients in the ICU 2. Patients age 18 and older Total number of central line days for patients age 18 and older in the ICU with a central line in place CCIS, MOHLTC Includes: 1. Patients in the ICU 2. Patients age 18 and older Data are available quarterly Data are collected at hospital institution level; can be aggregated up to Local Health Integration Network (LHIN) and provincial levels. Initial reporting started April 30, 2009 and included cumulative data for the three-month period January 01 to March 31, 2009. 2016/17 HSAA Technical Specifications Page 34
LIMITATIONS Specific limitations Currently, no information has been provided ADDITIONAL INFORMATION COMMENTS Additional information regarding the calculation, interpretation, data source, etc. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, HTTP://... RESPONSIBILITY FOR REPORTING O Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep. Aug 9 2002; 51(RR-10): 1-29. www.cdc.gov/mmwr/pdf/rr/rr5110.pdf Pittet D, Tarara D, Wemze; RP, 1994. Nosocomial bloodstream infection in critically ill patient. Excess length of stay, extra cost, and attributable mortality. JAMA 1994; (20): 271: 1598-1601. Health Service Providers DATE CREATED (YYYY- MM-DD) 2010-12-15 DATE LAST REVIEWED (YYYY-MM-DD) 2013-01-13 2016/17 HSAA Technical Specifications Page 35
INDICATOR DESCRIPTION INDICATOR NAME Detailed description of indicator INDICATOR CLASSIFICATION RATE OF HOSPITAL ACQUIRED METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS BACTEREMIA The rate of MRSA bacteremia is a measure of the incidence of laboratory confirmed bloodstream MRSA infection per 1,000 patient days Explanatory CALCULATION The total number of new nosocomial (i.e. hospital acquired) MRSA bacteremia cases in the reporting period multiplied by 1,000 NUMERATOR Self Reporting Initiative (SRI), Ontario Ministry of Health and Long-Term Care (MOHLTC) Includes: 1. All publicly funded hospitals 2. Inpatient beds 3. Laboratory-confirmed MRSA bacteremia cases (i.e. confirmation through a single positive blood culture for MRSA) 4. New nosocomial cases associated with the reporting facility is where the infection was not present on admission (i.e., onset of symptoms > 72 hours after admission) or the infection was present at the time of admission but was related to a previous admission to the same facility within the last 72 hrs. CALCULATION Excludes: 1. Long-term care beds The total number of patient days spent in-hospital in a reporting period DENOMINATOR GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released E.g. Be as specific as possible..data are Self Reporting Initiative (SRI), Ontario Ministry of Health and Long-Term Care (MOHLTC) Includes: 1. All publicly funded hospitals 2. Inpatient beds Excludes: 1. Long-term care beds Data are available each quarter for the previous quarter s data 2016/17 HSAA Technical Specifications Page 36
released annually in mid- May LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending Data are available at provincial, LHIN and hospital levels Data are available for the previous quarter as of December 2008 Data are self-reported by hospital. LIMITATIONS Specific limitations No individual patient data are available; therefore indicator cannot be broken down by socio-demographic characteristics. ADDITIONAL INFORMATION COMMENTS Additional information regarding the calculation, interpretation, data source, etc. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, HTTP://... RESPONSIBILITY FOR REPORTING Trending and comparisons are most valid by hospital type (e.g. small, large community, acute teaching, chronic care and rehab and mental health). This is in order to make limited adjustment for patient case mix. Patient Safety Website Health Service Providers DATE CREATED (YYYY- MM-DD) 2009-10-13 DATE LAST REVIEWED (YYYY-MM-DD) 2013-01-13 2016/17 HSAA Technical Specifications Page 37
INDICATOR NAME INDICATOR DESCRIPTION Detailed description of indicator INDICATOR CLASSIFICATION PERCENT OF PRIORITY 2, 3, AND 4 CASES COMPLETED WITHIN ACCESS TARGETS FOR CARDIAC BY-PASS SURGERY Descriptions of priority levels can be found in the link within the Reference section. Explanatory Step 1: Count the total number of cases completed for the reporting period by urgency category (Priority 2, 3 and 4). Please refer to the inclusion/exclusion criteria listed below. Step 2: Of the total count in step 1, count the number of cases where wait times are less than or equal to the provincial access target. Do this for all of the three urgency categories (Priority 2, 3, and 4). Step 3: The weighted percent of case completed within Priority 2, 3 and 4 access targets = sum of the counts by Urgency in step 2 divided by the sum of the counts by Priority in step 1 x 100 to get the percentage. CALCULATION Sample calculation: INDICATOR CCN Cardiac Registry. All Wait List Entries, off-listed as Procedure Started with procedure dates within date range submitted by hospitals to the CCN Cardiac Registry. Only isolated CABG surgery cases are included in the calculation. CABG surgery cases done in conjunction with other cardiac surgery procedures (i.e., valve surgery) are excluded. Cases with missing priority levels are excluded from the wait time calculation. Dates during which time a procedure is unable to take place for patient related and/or clinical reasons (Dates Affecting Readiness to Treat [DARTs]) are excluded from the wait time calculation. 2016/17 HSAA Technical Specifications Page 38
GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released E.g. Be as specific as possible..data are released annually in mid-may LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending CCN has provided the MOHLTC with historical data on this indicator quarterly for FYs 2013/14 and 2014/15 to allow analysis of historical trends. LIMITATIONS Specific limitations ADDITIONAL INFORMATION COMMENTS Additional information regarding the calculation, interpretation, data source, etc. All hospitals performing CABG surgery in Ontario submit their wait time data to the Cardiac Care Network (CCN) Cardiac Registry and are included in the wait time calculation. Calculated percent of cases completed within access targets is based only on the number of cases entered in the system on data cut date scheduled on the 3rd business day after month end. CCN applies rigorous compliance, data quality and resubmission processes to check on completeness, validity and accuracy. For any questions, please contact Garth Oakes, Senior Lead Knowledge Translation and Privacy, CCN (goakes@ccn.on.ca). As part of CCN s on-going data quality improvement effort, accuracy is one of the key areas monitored and assessed on a regular basis along with other data quality dimensions. CCN provides monthly missing data reports to assist hospital data entry staff to ensure the completeness of data at the facility level. Data are reviewed at each month end by CCN staff to assess data quality. For questions regarding data quality, please contact Garth Oakes, Senior Lead Knowledge Translation and Privacy, CCN (goakes@ccn.on.ca). REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, HTTP://... http://www.health.gov.on.ca/en/pro/programs/waittimes/surgery/target.aspx RESPONSBILITY FOR REPORTING Cardiac Care Network of Ontario 2016/17 HSAA Technical Specifications Page 39
DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) 2015-10-15 2016/17 HSAA Technical Specifications Page 40
INDICATOR NAME INDICATOR DESCRIPTION Detailed description of indicator INDICATOR CLASSIFICATION PERCENT OF PRIORITY 2, 3, AND 4 CASES COMPLETED WITHIN ACCESS TARGETS FOR CANCER SURGERY Descriptions of priority levels can be found in the link within the Reference section. Explanatory Step 1: Count the total number of cases completed for the reporting period by priority level (Priority 2, 3 and 4). Please refer to the inclusion/exclusion criteria listed below. Step 2: Of the total count in step 1, count the number of cases where wait times are less than or equal to the provincial targets. Do this for all of the three priority levels (Priority 2, 3, and 4). Step 3: The weighted percent of cases completed within Priority 2, 3 and 4 access targets = sum of the counts by Priority in step 2 divided by the sum of the counts by Priority in step 1 x 100 to get the percentage. Sample calculation: CALCULATION INDICATOR Cancer Care Ontario (ATC, 2015). Access to Care has implemented a robust data quality and compliance framework to assess data quality under four key dimensions: timeliness, validity, reliability and usability. The complete framework is available in the Wait Time Conditions of Funding and further information is available upon request at: ATCsupport@cancercare.on.ca. Wait Time is calculated based on closed cases submitted by hospitals through the WTIS. 1. All closed wait list entries with procedure dates within date range. 2. Must be 18 and older on the day the procedure was completed. 3. Procedures no longer required are excluded from wait time calculation. 4. Includes treatment for cancer procedures only. Procedures classified as NA are currently included. Diagnostic, palliative and reconstructive cancer 2016/17 HSAA Technical Specifications Page 41
procedures are excluded. Procedures on skin - carcinoma, skin-melanoma, and lymphomas are also excluded. 5. Procedures assigned as priority level 1 are excluded from wait time calculation. Cases with missing priority levels are also excluded. 6. Wait list entries identified by hospitals as data entry errors are also excluded. 7. If unavailable days fall outside the decision to treat date up to procedure date, unavailable days are not deducted from patients wait days. These are considered data entry errors. GEOGRAPHY & TIMING TIMING/FREQUENCY OF RELEASE How often, and when, are data being released E.g. Be as specific as possible..data are released annually in mid-may LEVELS OF COMPARABILITY Levels of geography for comparison TRENDING Years available for trending The calculated percent of cases completed within priority target can be compared with the historical trend published in the Government of Ontario wait time s website. All inclusions/exclusions criteria used are similar. Also, historical wait times trend for low volume hospitals/lhins will show as NV (no or low volume) instead of a calculated percent of cases completed within priority target. LIMITATIONS Specific limitations ADDITIONAL INFORMATION COMMENTS Additional information regarding the calculation, interpretation, data source, etc. Hospitals submitting wait time data voluntarily (not required to report) are included in wait time calculation. Calculated percent of cases completed within priority target is based only on the cases entered in the system. Logically, hospitals not reporting cases promptly are excluded at the time of data extraction. Volumes submitted by hospitals are checked monthly for completeness. Hospital volume is compared against the expected monthly average. Outliers are validated with hospitals if the wait days are not accurate. As part of ATC s on-going data quality and compliance processes with hospitals, accuracy is one of the key areas that have been monitored closely over time and assessed on a regular basis along with other data quality dimensions. ATC monitors data quality with hospitals on a weekly basis and works closely with 2016/17 HSAA Technical Specifications Page 42
hospitals WTIS coordinators to ensure data quality indicators and thresholds are met. If hospitals have challenges meeting data quality thresholds they may be excluded from wait time reporting calculations as well as public reporting. In these circumstances hospital, LHIN and/or ministry leadership is engaged to ensure hospital data quality is enhanced to become reportable as soon as possible. REFERENCES Provide URLs of any key references E.g. Diabetes in Canada, HTTP://... RESPONSBILITY FOR REPORTING http://www.health.gov.on.ca/en/pro/programs/waittimes/surgery/target.aspx Cancer Care Ontario DATE CREATED (YYYY- MM-DD) DATE LAST REVIEWED (YYYY-MM-DD) 2015-10-15 2016/17 HSAA Technical Specifications Page 43
INDICATOR DESCRIPTION INDICATOR NAME Detailed description of indicator INDICATOR CLASSIFICATION PERCENT OF PRIORITY 2, 3 AND 4 CASES COMPLETED WITHIN ACCESS TARGETS FOR CATARACT SURGERY Descriptions of priority levels can be found in the link within the Reference section. Explanatory Step 1: Count the total number of cases completed for the reporting period by priority level (Priority 2, 3 and 4). Please refer to the inclusion/exclusion criteria listed below. Step 2: Of the total count in step 1, count the number of cases where wait times are less than or equal to the provincial targets. Do this for all of the three priority levels (Priority 2, 3, and 4). Step 3: The weighted percent of cases completed within Priority 2, 3 and 4 access targets = sum of the counts by Priority in step 2 divided by the sum of the counts by Priority in step 1 x 100 to get the percentage. CALCULATION Sample calculation: INDICATOR WTIS, ATC, Cancer Care Ontario. Access to Care has implemented a robust data quality and compliance framework to assess data quality under four key dimensions: timeliness, validity, reliability and usability. The complete framework is available in the Wait Time Conditions of Funding and further information is available upon request at: ATCsupport@cancercare.on.ca. All closed Wait List Entries with procedure dates within date range submitted by hospitals through the Wait Time Information System. Patient age greater than equals to 18 years old on the day the procedure was completed. Procedures No Longer required (or cancelled cases) are excluded from wait time calculation. 2016/17 HSAA Technical Specifications Page 44