1. 1 Quality of Care – Quarterly Report Key Quality Indicators March 2008

2. 2 Table of Contents HHS Strategy Map3 Introduction4 Goal #1 - We meet or exceed our communities’ expectations5 Goal #2 - We are internationally recognized for the excellence or our patient-centered care, research and education11

3. 3 HHS Strategy Map Vision: 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 Goals 4. 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 Goals 1. 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: Respect Caring Innovation Accountability Priorities to Achieve Strategic Goals HHS 2007/08 Learning & Innovation Perspective Human Capital Information Capital Organization Capital CultureLeadership Corporate Change & Alignment Teamwork Internal Process Perspective Patient, Family, Customer Perspective Access to CareQuality Initiatives Operational Performance Healthy People and Environments System Thinking & Leadership Fiduciary Perspective

4. 4 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

5. 5 Strategic Goal #1 We meet or exceed our communities’ expectations Indicators: Emergency Department Wait Times By Site ALC Rates Wait Time Strategy by Service

6. 6 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: Resuscitation Triage 2: Emergent Triage 3: Urgent

7. 7 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 UrgentSource HHS ADT/ED Meditech System Triage 5: Non UrgentHAPS Indicator

8. 8 ALC Patient Trends 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

9. 9 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.

10. 10 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.

11. 11 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.

12. 12 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

13. 13 Infections Rates – Nosocomial VRE Rate 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. Rate per 1000 Pt.days

14. 14 Infections Rates – Nosocomial C-Difficile Rate 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 Rate per 1000 Pt.days

15. 15 Infections Rates – Nosocomial MRSA Rate 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

16. 16 Hospital Standardized Mortality Ratio (HSMR) Quality Indicator 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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