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Quality of Care – Quarterly ReportKey Quality Indicators

March 2008

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Table of Contents

HHS Strategy Map 3

Introduction 4

Goal #1 - We meet or exceed our communities’ expectations 5

Goal #2 - We are internationally recognized for the excellence or our patient-centered care, research and education 11

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HHS Strategy MapHHS Strategy MapVision:

Leaders in exemplary care, innovation and academic excellence.

Mission:To provide excellent health care for the people and communities we serve and to advance health care

through education and research.

Strategic Goals4. We have a sound financial base to

sustain our mission and achieve our vision.

5. We create a sustainable and aligned system through action and leadership

Strategic Goals1. We meet or exceed our communities’

expectations.2. We are internationally recognized for the

excellence of our patient-centred care,research and education.

3. We have a healthy work environment.

Values:RespectCaring

InnovationAccountability

Priorities to Achieve Strategic Goals

HHS 2007/08

Learning &InnovationPerspective

HumanCapital

InformationCapital

Organization Capital

Culture LeadershipCorporate Change

& AlignmentTeamwork

Internal Process Perspective

Patient, Family, Customer Perspective

Acc

ess

to C

are

Qualit

y Init

iati

ves

Opera

tional

Perf

orm

ance

Healt

hy P

eople

and

Envir

onm

ents

Syst

em

Thin

kin

g &

L

eaders

hip

Fiduciary Perspective

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The Hamilton Health Sciences (HHS) Quality of Care Report provides a quarterly report on Key Quality Indicators. They have been identified by the Quality Committee of the Board and grouped, where appropriately into the five Strategic Goals. The goal of the Operational Performance has measures captured in the Board Performance Monitor

1. Access to Care:

The timely access to health services is to achieve the best possible health outcomes. This includes a broad set of concerns that center on the degree to which needed services are available in a timely manner from the health care system.

2. Quality Initiatives:

The extent to which health services for individuals and populations are provided in a manner that increases the likelihood of desired health outcomes and are consistent with current evidence and best practice. This area includes Patient Safety, Appropriateness of Care and Application of best Practices.

3. Operational Performance:

The process of measuring, monitoring and adjusting organizational activity with the goal to optimize operational decisions and improve performance. This area includes initiatives related to efficiency and effectiveness.

4. Healthy People and Environments:

The ability to create and sustain a positive work environment. This area includes initiatives related to staff attraction, retention, motivation, culture, safety, teamwork and leadership.

5. System Thinking and Leadership:

The commitment to enhance the health care system through building and leveraging strategic relationships with other organizations and individuals in the public and private sectors (includes HHS Foundation). This area includes integration, innovation and knowledge transfer.

Many of the Quality Indicators have benchmarks or targets assigned to them based on either industry rates, best practice and/or LHIN/Ministry targets.

Introduction

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Strategic Goal #1

We meet or exceed our communities’ expectations

Indicators:• Emergency Department Wait Times By Site•ALC Rates •Wait Time Strategy by Service

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Emergency Department Wait Times By Triage Level 1, 2 and 3

Source: HHS ADT/ED Meditech System HAPS Indicator

Wait Times are based on the time from Arrival to Departure for all visits to the Emergency Department (ambulatory and inpatient) by triage category.

CTAS Codes:Triage 1: ResuscitationTriage 2: EmergentTriage 3: Urgent

E m e r g e n c y D e p t W a i t T i m e s f r o m A r r i v a l t o D e p a r t E D f o r T r i a g e 1 , 2 , 3

0 . 0 0

2 . 0 0

4 . 0 0

6 . 0 0

8 . 0 0

1 0 . 0 0

1 2 . 0 0

1 4 . 0 0

M a r - 0 7 A p r - 0 7 M a y - 0 7 J u n - 0 7 J u l - 0 7 A u g - 0 7 S e p - 0 7 O c t - 0 7 N o v - 0 7 D e c - 0 7 J a n - 0 8 F e b - 0 8 M a r - 0 8

G e n e r a l H e n d e r s o n M c M a s te r M O H T a r g e t

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Emergency Department

Wait Times By Triage Level 4 , 5

Wait Times are based on the time from Arrival to Departure for all visits to the Emergency Department (ambulatory and inpatient) by triage category.

CTAS Codes:Triage 4: Less Urgent Source HHS ADT/ED Meditech SystemTriage 5: Non Urgent HAPS Indicator

Emergency Dept Wait Time from Arrival to Depart Ed Triage 4 and 5

0.00

1.00

2.00

3.00

4.00

5.00

Mar-07 Apr-07 May-07 J un-07 J ul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 J an-08 Feb-08 Mar-08

General Henderson McMaster MOH Target

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ALC Patient Trends

A L C P a t i e n t s - b y A L C D e s i g n a t i o n

0 . 0

2 0 . 0

4 0 . 0

6 0 . 0

8 0 . 0

1 0 0 . 0

1 2 0 . 0

1 4 0 . 0

A p r - 0 7 M a y - 0 7 J u n - 0 7 J u l- 0 7 A u g - 0 7 S e p - 0 7 O c t - 0 7 N o v - 0 7 D e c - 0 7 J a n - 0 8 F e b - 0 8 M a r - 0 8

C o m p le x C a r e P a llia t iv e C o m p le x C a r e C o n v a le s c e n t C a r e H o m e H o s p ic e L o n g T e r m C a r e L o n g T e r m C a r e P a llia t iv e

ALC rates are ALC days as proportion of patient days. LHIN #4 baseline is 2005/06 rate and 2007/08 LHIN #4 target is based on a 2% proposed improvement by March 2008

ALC patients are those

waiting for an Alternate

Level of Care, as defined

by CIHI guidelines,

Source: HHS ADT Meditech System

A L C R a t e C o m p a r e d t o L H I N # 4 T a r g e t

0 . 0 0 %

2 . 0 0 %

4 . 0 0 %

6 . 0 0 %

8 . 0 0 %

1 0 . 0 0 %

1 2 . 0 0 %

1 4 . 0 0 %

1 6 . 0 0 %

1 8 . 0 0 %

M a r - 0 7 A p r - 0 7 M a y - 0 7 J u n - 0 7 J u l- 0 7 A u g - 0 7 S e p - 0 7 O c t - 0 7 N o v - 0 7 D e c - 0 7 J a n - 0 8 F e b - 0 8 M a r - 0 8

Pe

rce

nt

H H S P e r c e n t L H IN # 4 b a s e lin e L H IN # 4 T a r g e t

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Wait Time Information Strategy: Wait Times

Source: Provincial Wait Times Strategy web site

Red: above the LHIN #4 mean and provincial mean.Yellow: Equal to or below LHIN #4 mean and above provincial mean or above LHIN and below Prov.Green: Equal to or less than LHIN #4 mean and equal to or below provincial mean.

Surgical Oncology Oct - Dec 2007 Wait Time in Days

Provincial Mean

Provincial Median

LHIN #4 Mean HHS Mean

Bone, Joint and Muscle Cancers 18 11 29 32Breast Cancers 20 16 17 16Gastrointestinal Cancers 22 17 19 15Genitourinary Cancers 33 25 36 14Head and Neck Cancers 33 21 27 7Liver and Pancreatic Cancers 26 19 21 20Gynaecological Cancers 34 26 20 20Neurological Cancers 17 9 17 17Prostate Cancers 47 40 47 24Thyroid and Endocrine Cancers 58 43 49 No Value

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Wait Time Information Strategy: Wait Times

Source: Provincial Wait Times Strategy web site

Red: above the LHIN #4 mean and provincial mean.Yellow: Equal to or below LHIN #4 mean and above provincial mean or above LHIN and below Prov.Green: Equal to or less than LHIN #4 mean and equal to or below provincial mean.

Diagnostic Imaging Oct - Dec 2007 Wait Time in DaysProvincial Mean

Provincial Median

LHIN #4 Mean HHS Mean

Magnetic Resonance Imaging (MRI) 51 31 50 55Computerized Tomography (CT) 24 11 20 23

Orthopedic Surgery Joints Oct - Dec 2007 Wait Time in DaysProvincial Mean

Provincial Median

LHIN #4 Mean HHS Mean

Joint Hip Replacement 96 66 84 84Joinjt Knee Replacement 121 81 116 110

Cardiac Oct - Dec 2007 Wait Time in DaysProvincial Mean

Provincial Median

LHIN #4 Mean HHS Mean

Angiography 9 7 7 7Angioplasty 5 3 5 5Cardiac Bypass Surgery 21 15 15 15

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Wait Time Information Strategy: Wait Times

Red: above the LHIN #4 mean and provincial mean.Yellow: Equal to or below LHIN #4 mean and above provincial mean or above LHIN and below Prov.Green: Equal to or less than LHIN #4 mean and equal to or below provincial mean.

R a d ia t io n O n c o lo g y ( in c l C o m m u n i t y C l in ic s J a n u a r y 2 0 0 8

% o f P a t i e n t s S e e n w i t h i n P r o v i n c i a l T a r g e t P r o v i n c e

% o f P a t i e n t s S e e n w i t h i n P r o v i n c i a l T a r g e t - J C P

P r o v i n c i a l M e d i a n W a i t T i m e ( D a y s )

J u r a v i n s k i C a n c e r P r o g r a m M e d i a n W a i t T i m e ( D a y s )

R e fe r r a l t o C o n s u l t ( P r o v . T a r g e t 7 0 % w i t h i n 1 4 d a y s ) 5 9 . 5 % 7 1 . 4 % 1 3 1 1R e a d y t o T r e a t t o T r e a t m e n t ( P r o v . T a r g e t 7 0 % w i t h i n t a r g e t , a l l U r g e n c y c a t e g o r i e s ) 5 5 . 4 % 5 5 . 9 % 1 2 8

S y s t e m ic O n c o lo g y ( in c l C o m m u n i t y C l in ic s J a n u a r y 2 0 0 8

% o f P a t i e n t s S e e n w i t h i n P r o v i n c i a l T a r g e t P r o v i n c e

% o f P a t i e n t s S e e n w i t h i n P r o v i n c i a l T a r g e t - J C P

P r o v i n c i a l M e d i a n W a i t T i m e ( D a y s )

J u r a v i n s k i C a n c e r P r o g r a m M e d i a n W a i t T i m e ( D a y s )

R e fe r r a l t o C o n s u l t ( P r o v. T a r g e t 7 0 % w i t h i n 1 4 d a y s ) 4 7 . 3 % 4 3 . 8 % 1 5 1 7R e a d y t o T r e a t t o T r e a t m e n t ( P r o v. T a r g e t 7 0 % w i t h i n t a r g e t , a l l U r g e n c y c a t e g o r i e s ) 7 5 . 9 % 7 2 . 7 % 3 4

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Indicators: •Infection Rates •Hospital Standardized Mortality Rates (HSMR)

Strategic Goal #2

We are internationally recognized for the excellence of our patient-centered care, research and education

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Infections Rates – Nosocomial VRERate per 1000 Patient Days

VRE-Vancomycin Resistant Enterococcus

Source: Infection Control Database – Antibiotic resistant organisms (ARO’s)

A nosocomial incidence is defined as one which occurs 48 hours after admission to the facility. Rates are calculated per 1,000 patient days. HHS measures against itself as a target.

0

0 .2

0 .4

0 .6

0 .8

1

1 .2

1 .4

1 .6

1 .8

2

2 .2

2 .4

2 .6

2 .8

M U M C C h e d o k e G e n e r a l H e n d e r s o n

Rate

per

10

00

Pt.

days

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Infections Rates – Nosocomial C-DifficileRate per 1000 Patient Days

C Difficile - Clostridium difficile

Source: Infection Control Database

A nosocomial incidence is defined as one which occurs 48 hours after admission to the facility. Rates are calculated per 1,000 patient days. HHS measures against itself as a target

0

0 .1

0 .2

0 .3

0 .4

0 .5

0 .6

0 .7

0 .8

0 .9

1

M U M C C h e d o k e G e n e r a l H e n d e r s o n

Rate

per

10

00

Pt.

days

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Infections Rates – Nosocomial MRSARate per 1000 Patient Days

MRSA - Methicillin Resistant Staphylococus aureus

Source: Infection Control Database – Antibiotic resistant organisms (ARO’s)

.A nosocomial incidence is defined as one which occurs 48 hours after admission to the facility. Rates are calculated per 1,000 patient days. HHS measures against itself as a target

0

0 .20 .4

0 .6

0 .81

1 .21 .4

1 .6

1 .82

2 .2

2 .42 .6

2 .8

M U M C C h e d o k e G e n e r a l H e n d e r s o n

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Hospital Standardized Mortality Ratio (HSMR)Quality Indicator

6 5

1 1 0

8 9

8 5

7 4

1 1 3

6 5

8 3

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

1 0 0

1 1 0

1 2 0

1 s t Q t r F Y 0 7 / 0 8 2 n d Q t r F Y 0 7 / 0 8

G e n e r a l H e n d e r s o n M U M C H H S C o m b in e d

Source: CIHI HSMR Reports HSMR ratio is number of observed deaths/number of expected deaths X 100 and is used to assess a Hospital’s mortality rate. CIHI HSMR Corporate rates available up to and including September 2007

Upper Limit

HSMR is the ratio of observed to expected deaths. The calculation of expected deaths is based on weights (coefficients) derived from a logistic regression (LR) model. It is adjusted for age, sex, length of stay and admission category (transfers-in and co-morbidities). Annually an adjustment is made to exclude both palliative care patients and neonates less than 750 grams but not quarterly. It is also adjusted for the patient’s Charlson Index score, which reflects co-morbidities during a patient’s stay. The main purpose of HSMR ratios are to follow progress over time for an organization. Technically and statistically, CIHI cannot provide a separate HSMR for paediatric patients. MUMC reflects a combined results of both the adults and children population.

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