H-SAA Monitoring & Assessment Process & Overview
H-SAA MONITORING & ASSESSMENT PROCESS & OVERVIEW The Hospital Service Accountability Agreement (H-SAA) has been developed to monitor and analyze the current status of each public hospital within the Central East LHIN in accordance with established priorities and strategies. The dashboard is also used to mitigate issues and predict and manage performance. The primary objectives are: 1. Assessment of performance (all domains/quadrants for designated performance requirement/obligations) to ensure: a. Meeting negotiated H-SAA targets/performance standards/corridors; b. Comparison of actuals vs. budget and; c. Funding reconciliation. 2. Identify emerging issues, pressures, risks, as well as status, both at the organization level and the system level. 3. Work collaboratively with each hospital and other internal/external stakeholders in the development of innovative solutions to address and resolve identified issues, where applicable. The H-SAA Indicators are in alignment with Central East LHIN priorities and strategies, as well as the pan- LHIN and provincially-mandated priorities and strategies. Supplementary reports will be developed and revised as required to ensure flexibility and responsiveness to user requirements and to manage performance effectively. (e.g. Peer Comparison Report). Note : The data displayed is primarily sourced from each hospital s Hospital Annual Planning Submission (HAPS), quarterly reports via the Self Reporting Initiative (SRI) system & H-SAAs. Other data sources include Planning Decision Support Tool (PDST), Healthcare Indicator Tool (HIT), CIHI, etc.
28-13 Hospital Service Accountability Agreement LHIN - Surgery and Diagnostic Imaging Wait Times 9th Percentile Wait Time - Cancer Surgery (Days) 9th Percentile Wait Time - Cataract Surgery (Days) 9th Percentile Wait Time - Hip Replacement Surgery (Days) 6 4 2 2 15 1 5 2 15 1 5 Cancer Surgery (Days) Cataract Surgery (Days) Hip Replacement Surgery (Days) 4 2-2 -4-6 -2-4 -6-8 -2-4 -6 Performance Comments [Cancer Surgery] All hospitals were below their respective upper performance corridor, except RMH. The increased wait times for RMH were due to Christmas and March Break operating room (OR) closures. RMH is expected to be within corridor in 213/14 Q1. Performance Comments [Cataract Surgery] All hospitals were below their respective upper performance corridor. Performance Comments [Hip Replacement Surgery] All hospitals were below their respective upper performance corridor. 2 15 1 5 9th Percentile Wait Time - Knee Replacement Surgery (Days) 25 2 15 1 5 9th Percentile Wait Time - CT (Days) 1 8 6 4 2 9th Percentile Wait Time - MRI (Days) CMH Knee Replacement Surgery (Days) CT (Days) MRI (Days) 5-2 -4-2 -4-6 -5-6 -8-1 CMH Performance Comments [Knee Replacement Surgery] All hospitals were below their respective upper performance corridor. Performance Comments [CT] All hospitals were below their respective upper performance corridor. Performance Comments [MRI] NHH and LH were above their respective upper performance corridor. Due to large waitlists and steady demand, wait times have continued to increase. Additional volumes is an important factor in reducing wait times. The LHIN identified funds to purchase an additional 3,992 MRI hours and funding letters were sent to hospitals in early January 213. In mid-march, the Ministry also provided additional hours. These additional hours have assisted with decreasing wait times in Q4. However, earlier notification of additional hours was required to fully utilize the funding. To ensure a more sustainable improvement in MRI wait times, other mitigations, such as computerized booking and triage system, best practices in protocolling and appropriateness of exam, are being explored. Note: For those hospitals that did not meet their target, % above/below calculation is applied to the indicator-specific upper performance corridor No action - All hospitals are within the performance corridor and/or meeting target/budget Investigation required - 1 or 2 hospitals outside performance corridor and/or NOT meeting target/budget Monitoring required - 3 or 4 hospitals outside performance corridor and/or NOT meeting target/budget ATTENTION required - 5 or more hospitals outside the performance corridor and/or NOT meeting target/budget Page 3 of 11
28-13 Hospital Service Accountability Agreement LHIN - ER LOS and ALC 9th Percentile ER LOS for Admitted Patients 9th Percentile ER LOS for Non-Admitted Patients - Complex 6. 8. 5. 4. 7. 6. 5. 3. 4. 2. 1. 3. 2. 1... 3 9th Percentile ER LOS for Admitted Patients 4 9th Percentile ER LOS for Non-Admitted Patients - Complex 2 3 1 2 1-1 -2-1 -3-2 -4-3 Performance Comments [ER LOS of Admitted Patients] Central East LOS increased from 31.4 hours in Q2 12/13 to 35. hours in Q3 12/13. The LOS for this indicator decreased to 34.5 hours in the Central East LHIN for Q4 12/13 from 35. hours in Q3 12/13. While the Central East LHIN performance is below its MLPA target of 36. hours, it still remains above the provincial interim target of 25. hours. Central East LHIN s Q4 12/13 performance is the second most improved LHIN over last year s baseline. For the period January 213 to April 213 LHO (26.4), LHB (31.2), PRHC (29.8), RMH (26.5), RVAP (37.5) and RVC (33.4) were above the interim provincial target of 25. hours. Performance Comments [ER LOS for Non-Admitted Patients - Complex] Past Performance in this indicator has remained fairly stable over the last two quarters. For Non-Admitted High Acuity ED-LOS, Central East was at 6.7 hours for the first half of 12/13. The Central East LHIN LOS for this indicator has further decreased to 6.1 hours in Q4 12/13. In comparison to Q4 11/12, most LHINs noted a decrease in time spent in the ER for high acuity patients. The largest decrease was in Central East LHIN (1hr and 4mins). 6. 5. 4. 3. 9th Percentile ER LOS for Non-Admitted Patients - Minor/Uncomplicated 35. 3. 25. 2. 15. % ALC Days - Closed Cases [data for 212/13 Q3] 2. 1. 1. 5... 212/13 Q3 9th Percentile ER LOS for Non-Admitted Patients - Minor/Uncomplicated % ALC Days [data for 212/13 Q3] 2 1-1 -2-3 -4 1 8 6 4 2-2 -4-6 -8 Performance Comments [ER LOS for Non-Admitted Patients - Minor/Uncomplicated] Past Performance has remained stable over the last two quarters. For low acuity patients, time spent in the ED at the Central East LHIN decreased further to 4. hours for the third quarter 12/13. The performance was 6 minutes lower than the provincial average of 4.1 hours. The time spent in the ED for low acuity patients has not changed substantially for Q4 12/13 and has decreased by 18 minutes in comparison to Q4 11/12. There has been a slight increase of 6 minutes between Q3 12/13 and Q4 12/13. Performance Comments [% ALC Days] For the past few reporting periods, performance for the Central East LHIN has consistently been below the target of 15.2 except for Q3 of 211/12. The performance for Q3 212/13 has increased from 13.47% to 15. or 1.53 days. This is an increase of 11% though the performance for this indicator is still 13% below the Central East LHIN baseline and.2 below the Central East LHIN target of 15.2. Note: For those Hospitals who did not meet their Target, above/below calculation is applied to the indicator-specific Lower Performance Corridor Status - No action - All Hospitals are within the Performance Corridor, within Target or within Budget Status - Investigate required - 1 or 2 Hospitals outside Performance Corridor or NOT within Budget/Target Status - Monitor - 3 or 4 Hospitals outside Performance Corridor and/or NOT within Budget/Target Status - ATTENTION - 5 or more Hospitals outside the Performance Corridors or NOT meeting Target/Budget Page 4 of 11
28-13 Hospital Service Accountability Agreement LHIN - Mental Health, Substance Abuse & Selected CMG's Repeat Unplanned Emergency Visits within 3 days - Mental Health [Data for 212/13 Q2] Repeat Unplanned Emergency Visits within 3 days - Substance Abuse [Data for 212/13 Q2] 25. 2. 15. 3. 25. 2. 1. 5. 15. 1. 5. - 212/13 Q2. 212/13 Q2 Repeat Unplanned Emergency Visits within 3 days - Mental Health [Data for 212/13 Q2] Repeat Unplanned Emergency Visits within 3 days - Substance Abuse [Data for 212/13 Q2] 6 5 4 3 2 1-1 -2-3 16 14 12 1 8 6 4 2-2 Performance Comments [Repeat Unplanned Emergency Visits within 3 Days - Mental Health] Central East is on an average level with other GTA LHINS. Although we had expected to see no increase due to the implementation of the H2H strategy, this did not occur. Performance Comments [Repeat Unplanned Emergency Visits within 3 Days - Substance Abuse] As of April 1, 212, H2H, Hospital to Home Team was implemented in both the Northeast and Durham Clusters. Central East is on average with other GTA LHINS. The H2H Strategy is focused on Concurrent Disorders, and has an addictions component in the Durham Cluster. It was expected that this Team would reduce the unscheduled return visits for Addictions. Readmission within 3 days for Selected CMG's - CMG 1 [Data for 212/13 Q2] Readmission within 3 days for Selected CMG's - CMG 2 [Data for 212/13 Q2] 3. 25. 25. 2. 2. 15. 1. 15. 1. 5. 5. - 212/13 Q2-212/13 Q2 Selected CMG's by Hospital CMH: CHF PRHC: CHF LHC: CHF TSH: CHF Selected CMG's by CMH: COPD PRHC: COPD LHC: COPD TSH: COPD RMH: CHF NHH: COPD RVHS: CHF Hospital RMH: Diabetes NHH: Pneumonia RVHS: COPD Readmission within 3 days for Selected CMG's - CMG 1 [Data for 212/13 Q2] Readmission within 3 days for Selected CMG's - CMG 2 [Data for 212/13 Q2] 6 15% 5 4 1 5% 3-5% 2 1-1 -15% -2-25% Performance Comments [Readmission within 3 Days for Selcted CMG's - CMG 1] Performance Comments [Readmission within 3 Days for Selcted CMG's - CMG 2] Current MLPA Target is 14.9% for 212/13 current performance of 16.6% is above but consistent with recent performance. Current MLPA Target is 14.9% for 212/13 current performance of 16.6% is above but consistent with recent performance. Central East LHIN expects to see improvements in the baseline in 213 with a vascular health coalition dedicated to specific Central East LHIN expects to see improvements in the baseline in 213 with a vascular health coalition dedicated to specific vascular priorities that utilize quality improvement indicators to measure initiatives across the Central East LHIN in addressing vascular priorities that utilize quality improvement indicators to measure initiatives across the Central East LHIN in addressing avoidable hospital readmission rates. Incorporating education programs into the vascular priorities of the Central East LHIN avoidable hospital readmission rates. Incorporating education programs into the vascular priorities of the Central East LHIN for both professionals and patients in smoking cessation, diabetes management and rehabilitation for both stroke and cardiac for both professionals and patients in smoking cessation, diabetes management and rehabilitation for both stroke and cardiac and heart failure, alongside self-management and self-management support, this has identified the need for better and heart failure, alongside self-management and self-management support, this has identified the need for better communication initiatives between primary and tertiary HSPs. The coalition facilitated by the LHIN is incentivizing voluntary communication initiatives between primary and tertiary HSPs. The coalition facilitated by the LHIN is incentivizing voluntary integration proposals and vascular management partnerships both on a cluster-based level and LHIN-wide level. The Diabetes integration proposals and vascular management partnerships both on a cluster-based level and LHIN-wide level. The Diabetes Regional Coordination Centre alongside the Central East LHIN also facilitated a Value Stream mapping event in April 212, and Regional Coordination Centre alongside the Central East LHIN also facilitated a Value Stream mapping event in April 212, and the outcomes have been evaluated to include centralized intake as a core quality process improvement in diabetes health the outcomes have been evaluated to include centralized intake as a core quality process improvement in diabetes health services. All HSPs have surpassed their COPD and CHF targets with the exception of two hospitals. This has been influenced services. All HSPs have surpassed their COPD and CHF targets with the exception of two hospitals. This has been influenced by one hospital conducting a substantial "refresh" to external HCPs who also refer to the comparative hospital in the same by one hospital conducting a substantial "refresh" to external HCPs who also refer to the comparative hospital in the same Cluster that provides a Heart Failure Clinic. Cluster that provides a Heart Failure Clinic. Note: For those Hospitals who did not meet their Target, above/below calculation is applied to the indicator-specific Lower Performance Corridor Status - No action - All Hospitals are within the Performance Corridor, within Target or within Budget Status - Investigate required - 1 or 2 Hospitals outside Performance Corridor or NOT within Budget/Target Status - Monitor - 3 or 4 Hospitals outside Performance Corridor and/or NOT within Budget/Target Status - ATTENTION - 5 or more Hospitals outside the Performance Corridors or NOT meeting Target/Budget Page 5 of 11
28-13 Hospital Service Accountability Agreement LHIN - Total Margin, Current Ratio, Total Inpatient Acute and Day Surgery Total Margin ($) Current Ratio 3,, 2.5 25,, 2,, 15,, 2. 1.5 1,, 5,, 1..5 (5,,). Total Margin ($) Current Ratio 7% 6% 5% 4% 3% 2% 1% -1% -2% 1 8 6 4 2-2 Performance Comments [Total Margin] All hospitals were balanced or achieved a surplus, except NHH. NHH ended the year in a deficit position of ($668,131) due to net restructuring expenses and a net operating deficit (excludes the impact of facility amortization and interest on long-term liabilities). Performance Comments [Current Ratio] All hospitals were above their respective lower performance corridor, except TSH. Three hospitals, HHHS, LH and OSCMHS, met the Ministry benchmark of.8-2.. TSH ended the year at.32 and expressed extreme reservation regarding their ability to improve the current ratio to.38 or greater throughout the fiscal year. At the end of 212/13, the hospital had a balanced budget for the first time in 8 years and generated a small surplus of $885,, which is an initial step to rebuilding the cash balance. For 213/14, the H-SAA target for TSH is.33. 6, Total Inpatient Acute - Weighted Cases 6 Day Surgery - Weighted Visits 5, 5 4, 4 3, 3 2, 2 1, 1 Total Inpatient Acute - Weighted Cases Day Surgery - Weighted Visits 7 6 5 4 3 2 1-1 9 8 7 6 5 4 3 2 1 Performance Comments [Total Inpatient Acute - Weighted Cases] All hospitals were above their respective lower performance corridor, except HHHS. The inpatient discharges for HHHS decreased 13.8% in 212/13 from 211/12, which reduced the weighted cases. Alternate Level of Care (ALC) is a factor in their reduced number of discharges, as they have had several long-term ALC patients. Performance Comments [Day Surgery - Weighted Visits] All hospitals were above their respective lower performance corridor. Note: For those hospitals that did not meet their target, % above/below calculation is applied to the indicator-specific lower performance corridor No action - All hospitals are within the performance corridor and/or meeting target/budget Investigation required - 1 or 2 hospitals outside performance corridor and/or NOT meeting target/budget Monitoring required - 3 or 4 hospitals outside performance corridor and/or NOT meeting target/budget ATTENTION required - 5 or more hospitals outside the performance corridor and/or NOT meeting target/budget Page 6 of 11
28-13 Hospital Service Accountability Agreement LHIN - Complex Continuing Care and Ambulatory Care Complex Continuing Care - Weighted Patient Days Ambulatory Care - Visits [excl. ER] 45, 4, 35, 3, 25, 2, 15, 1, 5, 35, 3, 25, 2, 15, 1, 5, Complex Continuing Care - Weighted Patient Days Ambulatory Care - Visits [excl. ER] 4 7 35% 3 25% 2 15% 1 5% 6 5 4 3 2 1 Performance Comments [Complex Continuing Care - Weighted Patient Days] All hospitals were above their respective lower performance corridor. Performance Comments [Ambulatory Care - Visits [excl. ER]] All hospitals were above their respective lower performance corridor. Note: For those hospitals that did not meet their target, % above/below calculation is applied to the indicator-specific lower performance corridor No action - All hospitals are within the performance corridor and/or meeting target/budget Investigation required - 1 or 2 hospitals outside performance corridor and/or NOT meeting target/budget Monitoring required - 3 or 4 hospitals outside performance corridor and/or NOT meeting target/budget ATTENTION required - 5 or more hospitals outside the performance corridor and/or NOT meeting target/budget Page 7 of 11
28-13 Hospital Service Accountability Agreement LHIN - Patient Safety Indicators Patient Safety Indicators - Rate of Hospital Acquired Cases of Clostridium Difficile Infections 3.5 Patient Safety Indicators - Central Line Infection Rate 1.4 1.2 1..8.6.4.2. 3 2.5 2 1.5 1.5 LHB LHO NHH PRHC RMH RVAP RVC TSB TSG Rate of Hospital Acquired Cases of Clostridium Difficile Infections Central Line Infection Rate 4 4 3 3 2 2 1 1-1 -1-2 -2 LHB LHO NHH PRHC RMH RVAP RVC TSB TSG Performance Comments [Clostridium Difficile Infections] This indicator shows the number of patients newly diagnosed with hospital-associated Clostridium difficile Infection (CDI), divided by the number of patient days in that month, multiplied by 1,. Patient days are the number of days spent in a hospital for all patients. This rate calculation allows the level of hospital activity to be taken into account because this will fluctuate over time and is different across hospitals Clostridium difficile can be spread from person to person through either direct contact with the person who has CDI, or through contact with surfaces in the environment. Clostridium difficile can live a long time in the environment, making it difficult to erradicate. The provincial average for CDI is.33 and while most Central East LHIN hospital sites are above this average, it is encouraging to note that 8 of the 13 hospital sites have identified Clostridium difficile Infections as an quaility improvement area in their 213/14 Quality Improvement Plan (QIP). Performance Comments [Central Line Infection] This indicator shows the total number of newly diagnosed Central Line-Associated Primary Bloodstream Infection (CLI) cases in the Intensive Care Unit (ICU) after at least 48 hours of being placed on a central line, divided by the number of central line days in that reporting period, and multiplied by 1,. Central line days are the number of days spent on a central line for all patients in the ICU 18 years and older. Case count is the number of ICU patients 18 years and older diagnosed with CLI after at least 48 hours of being placed on a central line during the reporting period. Central Line Infection rates have been steadly declining in the province since 29. This indicator is measured as a rate per 1, days. For both of the hospitals sites that are above corridor, the case count for the infection rate is less than five (5) cases..5.4.4.3.3.2.2.1.1. Patient Safety Indicators - Rate of Hospital Acquired Cases of Methicillin Resistant Staphylococcus Aureus Bacterium 2.5 2 1.5 1.5 Patient Safety Indicators - Rate of Ventilator associated Pneumonia Rate of Hospital Acquired Cases of Methicillin Resistant Staphylococcus Aureus Bacterium 2 Rate of Ventilator associated Pneumonia 15 15 1 1 5 5-5 -5-1 -1-15 -15 Performance Comments [Methicillin Resistant Staphylococcus Aureus Bacterium] This indicator shows the number of patients newly diagnosed with hospital-associated MRSA bacteremia (bloodstream infection), divided by the number of patient days in that month, and multiplied by 1,. Patient days are the number of days spent in a hospital for all patients. This rate calculation allows the level of hospital activity to be taken into account because this will fluctuate over time and is different across hospitals. Case count is the number of patients with hospital-associated MRSA bacteremia during the reporting period. While The Scarborough Hospital - General site is above corridor is compares favouably across the province to other large community hospitals. Performance Comments [Ventilator associated Pneumonia] This indicator shows the total number of newly diagnosed Ventilator-Associated Pneumonia (VAP) cases in the Intensive Care Unit (ICU) after at least 48 hours of mechanical ventilation, divided by the number of ventilator days in that reporting period, and multiplied by 1,. Ventilator days are the number of days spent on a ventilator for all patients in the ICU 18 years and older. Case count is the number of ICU patients 18 years and older diagnosed with VAP after at least 48 hours of being placed on a ventilator (occasionally or continuously). The provincial average for VAP is.87. All Central East LHIN hospital sites compare favourably across the province to other sites of similar size or volume. Note: For those Hospitals who did not meet their Target, above/below calculation is applied to the indicator-specific Lower Performance Corridor Status - No action - All Hospitals are within the Performance Corridor, within Target or within Budget Status - Investigate required - 1 or 2 Hospitals outside Performance Corridor or NOT within Budget/Target Status - Monitor - 3 or 4 Hospitals outside Performance Corridor and/or NOT within Budget/Target Status - ATTENTION - 5 or more Hospitals outside the Performance Corridors or NOT meeting Target/Budget Page 8 of 11
28-13 Hospital Service Accountability Agreement LHIN - Patient Safety Indicators 1. Patient Safety Indicators - Rate of Hospital Acquired Cases of Vancomycin Resistant Enterococcus Bacterium.8.6.4.2. -2-4 -6-8 -1-12 Rate of Hospital Acquired Cases of Vancomycin Resistant Enterococcus Bacterium Performance Comments [Vancomycin Resistant Enterococcus Bacterium] This indicator shows the number of patients newly diagnosed with hospital-associated Vancomycin Resistant Enterococcus (VRE) bacteremia, divided by the number of patient days in that month, and multiplied by 1,. Patient days are the number of days spent in a hospital for all patients. This rate calculation allows the level of hospital activity to be taken into account because this will fluctuate over time and is different across hospitals. Case count is the number of patients with hospitalassociated VRE bacteremia during the reporting period. The provincial average for VRE is.1. All Central East LHIN hospitals are below the provincial average. Note: For those Hospitals who did not meet their Target, above/below calculation is applied to the indicator-specific Lower Performance Corridor Status - No action - All Hospitals are within the Performance Corridor, within Target or within Budget Status - Investigate required - 1 or 2 Hospitals outside Performance Corridor or NOT within Budget/Target Status - Monitor - 3 or 4 Hospitals outside Performance Corridor and/or NOT within Budget/Target Status - ATTENTION - 5 or more Hospitals outside the Performance Corridors or NOT meeting Target/Budget Page 9 of 11
28-13 Hospital Service Accountability Agreement LHIN - Orthopaedic Quality Indicators Hip Replacement Average Length of Stay (Days) Hip Replacement Proportion of Patients Discharged Home (%) 4.5 4. 3.5 3. 2.5 2. 1.5 1..5. 98. 96. 94. 92. 9. 88. 86. 84. 82. 8. 78. % Above/Below Performance Target Hip Replacement Average Length of Stay (Days) Hip Replacement Proportion of Patients Discharged Home (%) 2-5% -1 15% -15% -2 1-25% -3 5% -35% -4 Performance Comments [Hip Replacement Average Length of Stay] Performance Comments [Hip Replacement Proportion of Patients Discharged Home (%)] All hospitals met and exceeded the provincial target of 4.4 days. The provincial target is 9 with a 1 corridor. All hospitals were above the lower performance corridor. 4. 3.5 3. 2.5 2. 1.5 1..5. Knee Replacement Average Length of Stay (Days) 12. 1. 98. 96. 94. 92. 9. 88. 86. 84. Knee Replacement Proportion of Patients Discharged Home (%) % Above/Below Performance Target Knee Replacement Average Length of Stay (Days) Knee Replacement Proportion of Patients Discharged Home (%) 25% -1 2-2 -3-4 15% 1-5 5% -6 Performance Comments [Knee Replacement Average Length of Stay] Performance Comments [Replacement Proportion of Patients Discharged Home (%)] All hospitals met and exceeded the provincial target of 4.4 days. The provincial target is 9 with a 1 corridor. All hospitals were above the lower performance corridor. Note: For those hospitals that did not meet their target, % above/below calculation is applied to the indicator-specific target, or lower performance corridor, as indicated above No action - All hospitals are within the performance corridor and/or meeting target/budget Investigation required - 1 or 2 hospitals outside performance corridor and/or NOT meeting target/budget Monitoring required - 3 or 4 hospitals outside performance corridor and/or NOT meeting target/budget ATTENTION required - 5 or more hospitals outside the performance corridor and/or NOT meeting target/budget Page 1 of 11
H-SAA Indicator Name Financial Year End Total Margin Current Ratio Global Volumes Total Inpatient Acute Weighted Cases Day Surgery Weighted Visits CCC Weighted Patient Days Ambulatory Care Visits [excl. ER] 9th Percentile Wait Times Cancer Surgeries Cataract Surgeries Joint Replacement Surgery (Hip) Joint Replacement Surgery (Knee) Computed Tomography (CT) Magnetic Resonance Imaging (MRI) H-SAA Indicator Definition Total corporate (consolidated) revenues that exceed or fall short of total corporate (consolidated) expenses, excluding the impact of facility amortization and interest on long-term liabilities, in a given year Number of times a hospital s short-term obligations can be paid using the hospital s short-term assets Total acute inpatient discharges adjusted for resource intensity. Total day surgery visits adjusted for resource intensity using the Comprehensive Ambulatory Care Classification System (CACS), the methodology that is applied to ambulatory care data. Number of Complex Continuing Care (CCC) patient days reported within a given reporting period (number of days a patient is admitted and occupying a CCC bed within a designated unit before discharge from the organization). Number of visits (scheduled, non-scheduled) that are reported within an organization's clinics & non-surgical Day/Night Care units/functional centres (excluding Emergency Room Department visits) in a given reporting period. The time between a patient s and surgeon s decision to proceed with surgery, and the time the procedure is conducted. The 9th percentile is the point at which 9 of the patients received their treatment, while the other 1 waited longer. The time between a patient s and surgeon s decision to proceed with surgery, and the time the procedure is conducted. The 9th percentile is the point at which 9 of the patients received their treatment, while the other 1 waited longer. The time between a patient s and surgeon s decision to proceed with surgery, and the time the procedure is conducted. The 9th percentile is the point at which 9 of the patients received their treatment, while the other 1 waited longer. The time between a patient s and surgeon s decision to proceed with surgery, and the time the procedure is conducted. The 9th percentile is the point at which 9 of the patients received their treatment, while the other 1 waited longer. This indicator measures the wait time from when a diagnostic scan is ordered, until the time the actual exam is conducted. This interval is typically referred to as intent to treat. The 9th percentile is the point at which 9 of the patients received their treatment, while the other 1 waited longer. This indicator measures the wait time from when a diagnostic scan is ordered, until the time the actual exam is conducted. This interval is typically referred to as intent to treat. The 9th percentile is the point at which 9 of the patients received their treatment, while the other 1 waited longer. ER & ALC ER Length of Stay for Admitted Patients ER Length of Stay for Non-Admitted Complex ER Length of Stay for Non-admitted Minor ALC-LTC Volume Percentage ALC Days (closed cases) Readmission Within 3 Days For Selected CMGs Patient Safety Indicators Ventilator Associated Pneumonia (VAP) Rates Central Line Infection Rate of Hospital Acquired Clostridium Difficile Infections Rate of Hospital Acquired Vancomycin Resistant Enterococcus Bacteremia Rate of Hospital Acquired Methicillin Resistant Staphylococcus Aureus Bacteremia LHIN-Specific Indicators ALC Throughput Ratio Orthopaedic Quality Indicator Hip & Knee Replacement Propotion of Patients Discharged Home (%) Orthopaedic Quality Indicator Hip & Knee Replacement Average Length of Stay (days): Repeat Unplanned Emergency Visits Within 3 Days for Mental Health Conditions Repeat Unplanned Emergency Visits Within 3 Days for Substance Abuse Conditions The total emergency room (ER) length of stay (LOS) where 9 out of 1 admitted patients completed their visits. ER LOS is defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ER. The total emergency room (ER) length of stay (LOS) where 9 out of 1 non-admitted complex (Canadian Triage and Acuity Scale (CTAS) levels I, II and III) patients completed their visits. ER LOS is defined as the time from triage or registration, whichever comes first, to the time the patient leaves ER. The total emergency room (ER) length of stay (LOS) where 9 out of 1 non-admitted minor/uncomplicated (Canadian Triage and Acuity Scale (CTAS) levels IV and V) patients completed their visits. ER LOS is defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ER. Patients occupying an inpatient hospital bed for whom a physician (or designated other) has indicated that the acute care phase of treatment has ended, and the patient has been designated by the CCAC as ALC for Long Term Care (ALC-LTC). Hospitals are being measured on the total volume of patients designated ALC-LTC (by hospital corporation). Percentage of inpatient days where a physician (or designated other) has indicated that a patient occupying an acute care hospital bed has finished the acute care phase of his/her treatment. Cardiovascular: Stroke Age greater than or equal to age 45: 1. Hemorrhagic Event of Central Nervous System; 2. Unspecified Stroke COPD: 1. Chronic Obstructive Pulmonary Disease (greater than or equal to age 45) Pneumonia (All Ages): 1. Bacterial Pneumonia; 2. Viral/Unspecified Pneumonia; 3. Disease or Pleura Diabetes (All Ages): 1. Diabetes; Congestive Heart Failure (ages greater than or equal to 45); 1. Heart Failure without Cardiac Catheter; Cardiac CMGs (Ages greater than or equal to 4): 1. Arrhythmia without Cardiac Catheter; 2. Unstable Angina/Atherosclerotic Heart Disease without Cardiac Catheter; 3. Angina (except Unstable/Chest Pain without Cardiac Catheter Gastrointestinal CMGs (All Ages): 1. Minor Upper Gastrointestinal Intervention; 2. Severe Enteritis; 3. Complicated Ulcer; 4. Inflammatory Bowel Disease; 5. Gastrointestinal Haemorrhage; 6. Gastrointestinal Obstruction; 7. Esophagitis/Gastritis/Miscellaneous Digestive Disease; 8. Symptoms. Signs of Digestive System; 9. Other Gastrointestinal Disorder; 1. Cirrhosis/Alcoholic Hepatitis; 11. Liver Disease except Cirrhosis/Malignancy; 12. Disorder of Pancreas except Malignancy; 13. Disorder of Biliary Track Pneumonia occurring in patients requiring mechanical ventilation, intermittently or continuously, through a tracheostomy or endotracheal tube for more than 48 hours Central Line-Associated Primary Bloodstream Infection (CLI) Rate 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, patient days. The rate of VRE bacteremia is a measure of the incidence of laboratory confirmed bloodstream VRE infection per 1, patient days The rate of MRSA bacteremia is a measure of the incidence of laboratory confirmed bloodstream MRSA infection per 1, patient days ALC Throughput: Number of ALC patients discharged in a given time period/number of ALC patients designated in a given time period Values above 1. indicate that more ALC cases are being completed or closed than are being added to the waitlist in the time period selected. Numerator: Number of ALC cases discharged in a given month/denominator: Number of new ALC designations or re-designations in a given month Rate of patients discharged directly home from acute care (Recommended LHIN level target of 9 with a 1 corridor or +/- 9 percentage points from absolute target). Length of stay for patients who will be discharged directly home from acute care (Recommended LHIN level target is 4.4 days with a 9th percentile of 7 days) Percent of unplanned and unscheduled repeat emergency visits following an emergency visit for a mental health or condition. A visit is counted as an index visit (first visit) if it is followed by another visit that occurs in any Ontario hospital within 3 days. The index visit must be for a mental health condition; however, the repeat visit can be for any diagnosis within ICD-1-CA Chapter 5 (i.e. either a mental health condition or substance abuse condition). Percent of unplanned and unscheduled repeat emergency visits following an emergency visit for a substance abuse condition. A visit is counted as an index visit (first visit) if it is followed by another visit that occurs in any Ontario hospital within 3 days. The index visit must be for a substance abuse condition however, the repeat visit can be for any diagnosis within ICD-1-CA Chapter 5 (i.e. either a mental health OR substance abuse condition). Page 11 of 11