CORPORATE MONITOR
Key Performance Indicators
July - September 2010
Quarter 2
1
Table of Contents
 Introduction
3
 Goal #1 Excellence in Patient Care
4
 Goal #2 Active Healthy Work Environment
15
 Goal #3 Strong Financial Performance
22
2
Introduction
The West Lincoln Memorial Hospital Corporate Monitor provides a quarterly report on
Performance. The Indicators have been identified to reflect the Hospital’s three Strategic Goals,
which are:

Strategic Goal #1
Excellence in patient care

Strategic Goal #2
Active, healthy work environment

Strategic Goal #3
Strong financial performance
Highlights of Q2
• WLMH continues to meet or exceed targets in Patient Satisfaction for all areas monitored,
with the Obstetrical Department achieving the highest performer ranking in Ontario for
Community Hospitals;
• Average length of stay for Emergency Room patients continues to be too long. New initiative,
Patient Flow Coordinator, ramping up in January 2011 which should facilitate improvement;
• ALC Days remain constant over Q2 and are approaching the target, however WLMH
experiencing pressure in this area in Q3;
• Absenteeism rates continue to be above the OHA average. Recent initiatives include: memos
to staff and physicians to promote awareness and identification /counseling of individual high sick
time users.
3
Strategic Goal #1
Excellence in patient care
Key Performance Indicators:

Patient Overall Satisfaction Rate - Medicine/Surgery

Patient Overall Satisfaction Rate - Obstetrics

Patient Overall Satisfaction Rate - Emergency

Average Length of Stay for ER Patients By Triage Level

ER Patients Left Without Being Seen By Triage Level

Weighted Case Volume

Number Of Patients Admitted To ER (Admit No Bed)

Percent ALC Days On B-Ward, ICU And ER Admit No Bed

ER Average Length Of Stay For Admitted Patients

Infection Rates
4
Patient Overall Satisfaction Rate - Medicine/Surgery
• Analysis Period: Q1 2010/11
• Formula/Definition/Source:
95
90
Hospital Report
Patient Satisfaction
85
• Target: At a minimum higher than the Ontario
80
Community Hospital average and ultimately being the
Highest Performer for Ontario.
75
• Analysis: 31 persons responded representing 43.1%
70
surveyed. Respondents indicated improvement in the
following areas: courtesy of admission, how Doctors and
nurses worked together and the courtesy of the nurses. The
following was noted as areas for improvement: general
health teaching related to post discharge instructions and
wait time for the call bell to be answered.
55
50
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The report and comments are shared with staff.
Review the importance of health teaching and materials that
are available to assist with patient education. Remind staff
of the importance of a timely response to patient’s requests
for assistance.
60
A
• Action:
65
• Responsibility for Monitoring: Acute/CCC
Team
WLMH
Community Hospitals Ontario
Highest Performer Ontario
5
Patient Overall Satisfaction Rate - Obstetrics
100
• Analysis Period: Q1 2010/11
• Formula/Definition/Source: Hospital Report
90
Patient Satisfaction
• Target: At a minimum higher than the Ontario
80
Community Hospital average and ultimately being the
Highest Performer for Ontario.
• Analysis: 37 persons responded representing 50%
70
surveyed. WLMH performing at the highest level of
satisfaction compared to peers.
• Action: Review patient comments and scores for
60
improvement opportunities.
• Responsibility for Monitoring:
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50
Maternal Child and Women’s Health Team
WLMH
Community Hospitals Ontario
Highest Performer Ontario
6
Patient Overall Satisfaction Rate - ER
• Analysis Period: Q1 2010/11
• Formula/Definition/Source: Hospital Report
Patient Satisfaction
• Target:
At a minimum higher than the Community
Hospital average, and ultimately be the Highest Performer
for Ontario.
• Analysis:
93 persons responded representing 27.7%
surveyed. Response rates for ‘courtesy of doctors and staff’
as well as ‘how well doctors and nurses work together’
exceed the Ontario average. Areas to focus improvement
efforts on include wait times and explanation of wait times.
• Action:
Develop audit mechanism to measure and
evaluate wait time to triage.
• Responsibility for Monitoring:
and Ambulatory Care Team
ER Committee
100
95
90
85
80
75
70
65
60
55
50
7
8
9
7
8
9
7
7
8
8
9
9
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WLMH
Community Hospitals Ontario
Highest Performer Ontario
7
Average Length of Stay for ER Patients By Triage Level
• Analysis Period: Q2
2010/11
• Formula/Definition/Source: The average length
of stay for Triage 1, 2, 3, 4, and 5 patients. Derived from
CIHI NACRS data submissions.
100
• Formula/Definition/Source: The average length
of stay for Triage 1, 2, 3, 4, and 5 patients.
• Target:
HAPS/H-SAA
• 90% of cases in Triage 1 and 2 with a LOS < 8 hours 90% of
cases in Triage 3 with a LOS < 6 hours and 90% of cases in
Triage 5 with a LOS < 4 hours
• Analysis: Length of stay for all triage groupings below
HAPS/H-SAA targets
• Action:The ER committee in conjunction with the reports
from Decision Support will review the major ambulatory
clusters with performance below the desired performance
level of 90%.
• Responsibility for Monitoring:
% discharged within HAPS timeframe
90
80
70
Triage 1 & 2
Most Critcal
Triage 3
60
50
Triage 4 & 5
40
30
Target
20
10
0
1
Q
09
2
Q
09
3
Q
09
4
Q
09
1
Q
10
2
Q
10
ER Committee
working with Decision Support.
8
ER Patients Left Without Being Seen By Triage Level
• Analysis Period: Q2
2010/11
7
• Formula/Definition/Source: The percentage of
patients seen in ER who left without being seen for Triage 1,
2, 3, 4, and 5 patients. Derived from CIHI NACRS
submissions.
6
5
• Target:
10
10
Q2
Q1
09
09
ER Committee
Q4
working with Decision Support.
0
Q3
• Responsibility for Monitoring:
1
09
reports from Decision Support will review the major
ambulatory clusters with performance below the desired
performance level of 0%.
Triage 4 & 5
2
09
• Action: The ER committee in conjunction with the
3
Q2
WLMH did not meet 0% target for Triage 3, 4
& 5 in Q2 2010.
Percent
• Analysis:
Triage 1 & 2
Most Critcal
Triage 3
4
Q1
No established LHIN wide target, however
discussion has been that 0% should be used for Triage 1, 2
and 3.
9
Weighted Case Volume
10
Q
2
10
1
Q
1
Q
Management
09
•Responsibility for Monitoring:
09
To achieve targets must reduce weighted
case volume, review is underway.
4
•Action:
Q
inpatient and day surgery combined) within target.
09
•Analysis: Q2 2010 total weighted cases (acute
3
case volumes in HAPS agreement (720 per quarter plus
or minus 10%).
Q
•Target: Monitor and work towards meeting weighted
09
cases for acute inpatients and day surgical cases for
the time period compared to the HAPS agreement
volumes.
Weighted Cases
•Formula/Definition/Source: The weighted
2
Q2 2010/11
Q
•Analysis Period:
850
800
750
700
650
600
550
500
450
400
350
300
250
200
150
100
50
0
Acute Inpatient
Day Surgery
HAPS target
Lower limit (-10%)
Upper limit (+10%)
10
Number Of Patients Admitted To ER (Admit No Bed)
200
180
160
patients admitted to the ER as a result of no bed
availability or no appropriate bed availability. Derived
from MEDITECH monthly census.
140
20
10
Q
2
10
Q
1
09
Q
4
09
0
3
•Responsibility for Monitoring:
40
Q
To achieve targets must try to keep ALC
rate down to maintain availability of beds on Medical
unit.
60
09
•Action:
80
09
trended.
100
1
•Analysis: Tracking above target for all quarters
120
Q
•Target: 60 per quarter.
Number
•Formula/Definition/Source: The number of
2
Q2 2010/11
Q
•Analysis Period:
Management
Actual
Target
11
Percent ALC Days On B-Ward, ICU And ER Admit No Bed
30.0
•Analysis Period:
Q2 2010/11
25.0
•Formula/Definition/Source:
•Target: MOHLTC provincial target of 11%.
20.0
Percent
The number of
ALC bed days on C-ward, ICU and ER admit no bed
expressed as a percentage of patient days for same
areas. Derived from MEDITECH daily census and ALC
reporting by Discharge Planner.
15.0
10.0
•Analysis: Above provincial target for all periods
•Responsibility for Monitoring:
Actual
10
Q
2
10
Q
1
09
Q
4
09
Q
3
09
Q
2
09
Continue to monitor appropriateness of
admissions, encourage compliance with anticipated
date of discharge times and review of ALC
designations.
0.0
1
•Action:
5.0
Q
trended however a significant downward trend is noted
from Q1 09 to Q1 10. A 1.0% increase from Q1 10 to
Q2 10.
Target
Management
12
ER Average Length Of Stay For Admitted Patients
12.0
Q2 2010/11
•Formula/Definition/Source:
The average
number of hours for patients admitted through the ER
from the date/time the decision to admit the patient was
made to the date/time patient leaves ER. Derived from
CIHI NACRS data submissions.
•Target: HNHB LHIN ALC Steering Committee target
of < 6 hours.
•Analysis: Above HNHB LHIN target for all quarters
trended.
•Action: To achieve target must continue to monitor
appropriateness of admissions, encourage compliance
with anticipated date of discharge times and continue to
work with Community Care Access Centre (CCAC).
New initiative, Patient Flow Coordinator, ramping up in
January 2011 which should facilitate improvement.
Average Number Of Hours
•Analysis Period:
10.0
8.0
6.0
4.0
2.0
0.0
Q1
09
Q2
09
Actual
Q3
09
Q4
09
Q1
10
Q2
10
Target
•Responsibility for Monitoring:
Management
13
Infection Rates
Infection Rates
• Analysis Period: Q2 2010/11
• Formula/Definition/Source: Rate of Infection per
1000 patient days.
• Target:
To achieve 0 infection rate.
• Analysis: Achieved target for all agents in Q2.
Rate/1000 Patient Days
2.5
2
1.5
1
0.5
• Action: Infection Prevention and Control, managers and
Prevention and Control Committee
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• Responsibility for Monitoring:
Fe
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0
0
staff continue diligence in maintaining policies and
practices.
Infection
C-Difficile
MRSA
VRE
14
Strategic Goal #2
To achieve an active healthy work environment
Key Performance Indicators:

Absenteeism Rate

Overtime Rate

Call-back Rate

Workforce Planning (2)

Performance Appraisal Completion Rate
15
Absenteeism Rate
• Analysis Period:
Q2 2010/11
9
• Formula/Definition/Source:
Average
number of sick days per person per employment
category. Payroll System.
8
7
• Target: Reduce total sick time, at a maximum meet
the OHA average per person benchmark.
6
5
Administration/
Clerical
4
Nursing/
Paramedical
• Analysis:
The Service staff group has fallen below
the OHA average benchmark. Other areas above the
OHA average benchmark. Increase in absenteeism in
Nursing/Paramedical for this quarter.
X
X
Managers and Employee Health to review
averages for each unit and continue diligence in followup with employees according to Support and
X
Service
X -OHA Average
3
X
• Action:
X
X
X
X
2
X
X
X
X
1
Attendance Awareness Program.
0
Oct-Dec/09
• Responsibility for Monitoring:
JanMar/10
AprJune/10
JulySep/10
Management
16
Overtime Rate- Total
• Analysis Period: Q2
2010/11
180
160
• Formula/Definition/Source: Actual overtime
• Target:
To meet or achieve under budget status.
• Analysis:
Overall overtime is under budget by 7%
for the first half of 2010/11. Obstetrics and
Switchboard running over budget due to workload and
sick time issues.
140
Percentage of Budget
hours over total budgeted overtime hours x100. Payroll
system.
120
100
80
60
40
20
Managers and Employee Health continue
diligence in follow-up with employees according to
Support and Attendance Awareness Program to reduce
regular staffing at overtime rates.
• Responsibility for Monitoring:
0
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Au
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Oc
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Fe
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• Action:
2008/09
2009/10
2010/11
Target
Management Group
17
Call-back Rates
• Analysis Period: Q2 2010/11
• Formula/Definition/Source: Actual call-back
• Target: Budgeted call-back hours.
• Analysis: Exceeding target on a regular basis in
Radiology due to increased call-back from ER. Also
exceeding targets in the Surgical Suite and Obstetrics
due to increase need in Obstetrical surgery.
• Action:
Continue to monitor. Review need for night
shift in Radiology (only when break even point is met
for costs).
• Responsibility for Monitoring:
Management Group
160
Percentage of Budget
hours over total budgeted call-back hours. Payroll
system.
180
140
120
100
80
60
40
20
0
Q1
2009
Q2
2009
Q3
2009
Q4
2009
Q1
2010
Q2
2010
Total Callback rate
Target
18
Workforce Planning
• Analysis Period:
Annual Slide- 2009/10
Calculated at December 31st each year.
50
45
• Formula/Definition/Source:
• Analysis:
30
25
20
15
10
5
0
e
Recruit.
20
08
-a
g
• Action:
20
09
-a
g
55
Increase over last year in total number
of staff eligible for retirement in all areas noted. Largest
risk in percentage of management staff eligible to
retire, small pool of individuals
35
e
55
20
08
-a
ge
60
20
09
-a
ge
60
20
08
-t o
ta
l
20
09
-t o
ta
l
• Target: Not applicable
40
Percentage
Percentage of
Nursing/Management staff that have attained age 55,
60 and total over 55 age.
Age (Years)
• Responsibility for Monitoring:
Management
RN
RPN
Management
19
Workforce Planning
Average Age
40
30
20
10
ge
r
an
a
ge
r
an
a
20
08
-M
29
90
-M
PN
20
09
-R
Staff Group
are eligible to retire, small pool of individuals.
Provincial averages not yet available, however WLMH
is trending up. WLMH must compete for staffing.
Provincial
WLMH
Percentage over age 55
Continue with development of recruitment
ge
r
an
a
20
09
-M
an
a
ge
r
PN
20
08
-M
20
09
-R
N
PN
20
08
-R
20
09
-R
Management
N
• Responsibility for Monitoring:
50
45
40
35
30
25
20
15
10
5
0
20
08
-R
and succession planning strategies.
Percentage
• Action:
20
09
-R
20
08
-R
• Target: Not applicable
• Analysis: Large percentage of management staff
PN
0
N
Average age
and eligibility for retirement of Nursing/Management
staff compared to provincial average.
50
N
• Formula/Definition/Source:
60
20
08
-R
Annual Slide- 2009/10
Calculated at December 31st each year.
Age (years)
• Analysis Period:
Staff Group
Provincial
WLMH
20
Performance Appraisal Completion Rate
• Analysis Period:
Q2 2010/11
120
• Formula/Definition/Source:
The cumulative 100
number of Performance Appraisals completed for the
period over the cumulative total number of
80
Performance Appraisals to be completed for the period
X 100. Human Resources.
60
20
• Action:
• Responsibility for Monitoring:
Management Group
20
10
/1
1
20
10
/1
1
Q
2
sc
al
20
07
/0
8
0
Fi
Each department manager has received an
updated spreadsheet indicating completed and
outstanding Performance Appraisals with expected
date for completion.
Q
1
Total completion rate at 66%.
sc
al
20
08
/0
9
Fi
sc
al
20
09
/1
0
• Analysis:
40
Fi
• Target: 100% completion by March 31, 2011
PA Completion Rate
Goal
21
Strategic Goal #3
To maintain strong financial performance
Key Performance Indicators:

Operating Margin

Current Ratio
22
Operating Margin
• Analysis Period:
Q2 2010/11
• Formula/Definition/Source:
3
2
Surplus
(deficit) over total income x 100.
1
20
10
/1
1
Q2
20
10
/1
1
Q1
20
09
/1
0
-1
20
08
/0
9
Year to date, an operating deficit of
$391,844 which is an operating margin of -3.56.
Budgeted deficit year to date $206,553 which is an
operating margin of -2.66.
20
07
/0
8
• Analysis:
0
20
05
/0
6
0% - LHIN expectation is that net margin be
0% or higher.
20
06
/0
7
• Target:
-2
-3
• Action:
Continue work on budget balancing
strategies as the LHIN expectation is a balanced
budget for 20011/12.
-4
-5
• Responsibility for Monitoring:
Management Group
Total Margin
Standard
23
Current Ratio
3
• Analysis Period:
Q2 2010/11
2.5
• Formula/Definition/Source:
The current
assets over current liabilities. Trial Balance submission
to the MOHLTC/LHIN.
2
1.5
20
10
/1
1
20
10
/1
1
Q
2
Management Group
0
Q
1
• Responsibility for Monitoring:
0.5
20
09
/1
0
Year to date the current ratio is 1.96
which is under the performance corridor set by the
LHIN. It is imperative to maintain a positive working
capital as it largely affects the current ratio.
20
08
/0
9
• Analysis:
1
20
07
/0
8
2.63- 3.21 is the MOHLTC standard.
20
06
/0
7
• Target:
Current Ratio
24