1. Health Equity at UHN: Our Quality Journey Jan Lackstrom Chair, Health Equity Council Senior Clinical Director

2. Moving from theory to practice: Key enablers UHN Board of Directors – Annual report to the Quality Committee of the Board – Each program to choose on quality indicator to report on Values and Business case Health Equity Council – Sr. Vice President accountability – Annual report to the UHN Quality Committee – Support programs in developing indicators 2

3. Key Supports Performance Measurement Department – Leadership – Dedicated staff including a biostatistician – Purchased improved level of postal code data Operational Vice-Presidents and Directors Who knew? – Secret champions came from everywhere Chair of Woman’s Health Line staff, Collaborative Academic Practice, Physicians, Human Resources Corporate Planning 3

4. UHN Indicators Inclusion of health equity indicators in program based quality reports – 16 programs have reported – Themes include: Wait times Readmissions Cancellation rates Patient satisfaction Access to care 4

5. BSC Caring Dimension Analysis Indicator Measures Statistically Significant Findings FY09-10FY11-12FY12-13 AgeSexLangIncomeAgeSexLangIncomeAgeSexLangIncome Hospital Standardized Mortality Ratio (HSMR) Infection of Clostridium Difficile (C.Diff) Central Line Infections ED LOS for Admitted Patients P4R target 90 th percentile Surgeries (Avoidable) Cancelled Within 48 Hours - significant with p-value < 0.05; - highly significant with p-value < 0.01; - not significant 5

6. Health Equity FY13-14 Program Based Health Equity Indicators - significant with p-value < 0.05; - highly significant with p-value < 0.01; - not significant Program/ServiceIndicator Measures Statistically Significant Findings Date of BQ Presentation AgeSexLanguageIncome KNCInpatient 30-Day Readmissions Mar 31, 2014 Infection Prevention and Control MRSA Screening Collected Within 6 Hours of Admission Mar 31, 2014 Transplant 1) Access to Evaluation Feb 24, 2014 2) Access to Listing 3) Access to Transplant MCC – CMH (Psychiatry) 1) Restraint Used in PESU Feb 24, 2014 2) Restraint Used in Inpatient Units - access ; - outcome; - wait time 6