__________________________________________________
H-SAA MONITORING & ASSESSMENT PROCESS & OVERVIEW
2011/12 Q2
__________________________________________________
H‐SAA MONITORING & ASSESSMENT PROCESS & OVERVIEW
___________________________________________________________
The Hospital Service Accountability Agreement Dashboard has been developed to enable users in how best to gauge & determine the current status of each public hospital within Central East LHIN in accordance with established priorities and strategies. This will facilitate individual Hospital reviews that will be conducted for each reporting period (fiscal quarters & Year End). The primary objectives are:
1. Assessment of performance (all domains/quadrants for designated performance requirement/obligations):
a. Meeting negotiated targets/performance standards/corridors, b. Comparison of actuals vs budget and;
c. Funding reconciliation;
***As defined per accountability agreements;
2. Identification of emerging issues/pressures/risks as well as status, both at the organization level and how this impacts at the
system level (facilitating quick assessment of current status for further analysis if required).
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.
***Dialogue and subsequent follow‐up where required and in accordance with the "Prioritization Framework" and principles contained within the H‐SAA (e.g. Performance Management and Improvement, Section 9.0).
***Development/Implementation of recommended solutions and outcome assessments going‐forward (analysis of impact).
Alignment with CE LHIN priorities and strategies as well as provincially‐mandated priorities and strategies. The key mandate is to
develop a better understanding of each Hospital's performance for each indicator in each quadrant as well as in relation to the pressures they are facing and how this is impacting at various levels. ***Supplementary reports will be developed and revised as needed/required to ensure flexibility and responsiveness to successfully meet current and future commitments (e.g. Peer Comparison Report). Note : The data displayed is primarily sourced from each Hospital’s Hospital Annual Planning Submission (2008), Quarterly Reports via the Web‐Enabled Reporting System (WERS) & 2008‐10 Hospital Signed Accountability Agreement (H‐SAA) Schedule D. Other data sources includes, Planning Decision Support Tool (PDST), Healthcare Indicator Tool (HIT), CIHI, etc.
Page 2 of 13
2008-12 Hospital Service Accountability Agreement
2011/12 Q2 LHIN Dashboard - Financial/Volume/Surgical & DI Wait Times
CENTRAL EAST LOCAL HEALTH INTEGRATION NETWORK
Total Margin
CMH
RMH
PRHC
HHHS
NHH
Current Ratio
LHC
RVHS
TSH
OSMHS
CMH
RMH
PRHC
HHHS
NHH
Total Weighted Cases (Inpatient & Day Surgery)
LHC
RVHS
TSH
CMH
OSMHS
RMH
% Surplus/Deficit of LHIN Base Allocation
PRHC
HHHS
NHH
LHC
RVHS
TSH
OSMHS
TSH
OSMHS
% Above/Below Performance Standard
Total Weighted Cases (Inpatient & Day Surgery)
% Above/Below Performance Standard
Current Ratio
x
CMH
RMH
PRHC
HHHS
NHH
LHC
RVHS
Performance Comments [YE Total Margin]
TSH
OSMHS
CMH
RMH
PRHC
Mental Health Patient Days [PD]
PRHC
HHHS
NHH
LHC
RVHS
TSH
RMH
OSMHS
RMH
PRHC
HHHS
NHH
LHC
RVHS
TSH
CMH
OSMHS
RMH
PRHC
RVHS
Performance Commentary [MH PD]
NHH
LHC
RVHS
Dashboard
Ambulatory Care Visits [excl. ER]
LHC
RVHS
TSH
Rehab [PD]
OSMHS
CMH
RMH
PRHC
OSMHS
CMH
RMH
PRHC
HHHS
NHH
CCC Weighted Patient Days
LHC
RVHS
Rehab [PD] TSH
Performance Comments [Rehab, CCC Wtd PD]
Dashboard
HHHS
NHH
LHC
RVHS
TSH
OSMHS
% Above/Below Performance Standard
Ambulatory Care Visits [excl. ER]
% Above/Below Performance Standard
CCC Weighted Patient Days & Rehab [PD]
TSH
HHHS
Performance Comments [Total Wtd Cases]
Dashboard
PRHC
HHHS
NHH
CCC Weighted Patient Days
% Above/Below Performance Standard
Mental Health Patient Days [PD]
CMH
LHC
CCC Weighted Patient Days & Rehab [PD]
CMH
RMH
NHH
All CE LHIN hospitals have reported in their forecast to be within their
8 out of 9 CE LHIN hospitals have reported in their forecast to be within
H-SAA corridors for Total Weighted Cases (Inpatient & Day surgery) at
their H-SAA corridors except CMH which is lower by 0.04 (not material).
2011/12 YE.
All CE LHIN hospitals have reported in their forecast to balance at
2011/12 YE.
CMH
HHHS
Performance Comments [Current Ratio]
Dashboard
OSMHS
CMH
RMH
PRHC
HHHS
NHH
LHC
RVHS
Performance Comments [Amb. Care Visits]
Dashboard
TSH
OSMHS
Dashboard
All CE LHIN hospitals have reported in their forecast to be within their HAll CE LHIN hospitals have reported in their forecast to be within their HAll CE LHIN hospitals have reported in their forecast to be within their HSAA corridors for CCC Weighted Patient Days & Rehab Patient Days at
SAA corridors for Mental Health Patient Days at 2011/12 YE.
SAA corridors for Ambulatory Care Visits (exclude ER) at 2011/12 YE.
2011/12 YE.
90th Percentile Wait Time ‐ Cataract Surgery 90th Percentile Wait Time ‐ Cancer Surgery CMH
RMH
PRHC
HHHS
NHH
LHC
RVHS
TSH
CMH
RMH
CMH
RMH
PRHC
HHHS
NHH
LHC
HHHS
NHH
LHC
RVHS
TSH
CMH
RMH
% Above/Below Performance Standard
Cataract Surgery % Above/Below Performance Standard
Cancer Surgery Performance Comments [Cancer Surgery]
PRHC
90th Percentile Wait Time ‐ Hip Relacement
RVHS
TSH
CMH
RMH
PRHC
HHHS
NHH
LHC
Performance Comments [Cataract Surgery]
Dashboard
PRHC
HHHS
NHH
LHC
RVHS
TSH
RVHS
TSH
% Above/Below Performance Standard
Hip Relacement
RVHS
TSH
CMH
RMH
PRHC
HHHS
NHH
LHC
Performance Comments [Hip & Knee Replacement Surgery]
Dashboard
Dashboard
5 out of 6 CE LHIN hospitals are within their H-SAA corridors in Q2, with
PRHC above its H-SAA upper corridor by 16 days, which is mainly due to
5 out of 6 CE LHIN hospitals are within their H-SAA corridors in Q2, with
5 out of 6 CE LHIN hospitals are within their H-SAA corridors in Q2, with
a data quality issue identified at one of the ophthalmologist’s offices.
TSH above its H-SAA upper corridor by 2 days (not material).
RVHS above its H-SAA upper corridor by 104 days, which is mainly due to
the unavailability of one orthopeadic surgeon.
When the data quality issue is addressed and a new surgeon is hired in
CE LHIN plans to invite Cancer Care Ontario to the Wait Times Strategy
November, PRHC expects to lower its cataract wait times and meet the HWorking Group meeting in the near future to discuss cancer surgery
RVHS has resolved this staffing issue in October, and expects to lower its
SAA target by 2011/12 Q4. In addition, CE LHIN is funding 801 more
wait times targets.
hips replacement wait times and meet the H-SAA target by 2011/12 Q4.
procedures at TSH, which will help with wait times reduction in the CE
LHIN.
90th Percentile Wait Time ‐ Knee Relacement
CMH
RMH
PRHC
HHHS
NHH
LHC
90th Percentile Wait Time ‐ CT
RVHS
TSH
CMH
RMH
% Above/Below Performance Standard
90th Percentile Wait Time ‐ Knee Relacement
CMH
RMH
PRHC
Performance Comments [CT & MRI]
HHHS
NHH
LHC
PRHC
HHHS
NHH
90th Percentile Wait Time ‐ MRI
LHC
RVHS
TSH
CMH
RMH
% Above/Below Performance Standard
90th Percentile Wait Time ‐ CT
RVHS
TSH
Dashboard
All CE LHIN hospitals are within their knee replacement wait times HSAA corridor in Q2.
CMH
RMH
PRHC
HHHS
NHH
Performance Comments [Average Length of Stay]
LHC
RVHS
TSH
Dashboard
All CE LHIN hospitals are within their CT wait times H-SAA corridors in
Q2.
\
PRHC
HHHS
NHH
LHC
RVHS
CMH
RMH
PRHC
HHHS
NHH
Performance Comments [% of Patients Discharged Home ]
LHC
RVHS
4 out of 6 CE LHIN hospitals are within their H-SAA corridors in Q2, with
NHH above its upper corridor by 3 days (not material) and LHC by 51
days mainly due to its aged MRI machine and the inreasing demand
caused by referrals.
With the aged MRI machine replaced in August 2011 and additional $285k
UPF funding from the CE LHIN to help LHC maintain the same level of
funded volumes as prior year, LHC expects to lower its MRI wait times
and meet the H-SAA target by 2011/12 Q4. In addition, CE LHIN is
providing additional funding up to identified hospital capacity as a means
to improve MRI performance in Q4.
***Note: For those Hospitals who did not meet their Target, above/below calculation is applied to their indicator-specific Lower Performance Corridors for each respective organization
-
TSH
Dashboard
Legend: Hospitals with Performance outcomes outside the specified Performance Corridors or not within Budget/Target, further investigation is recommended.
|| Status
|| Status
|| Status
|| Status
TSH
% Above/Below Performance Standard
90th Percentile Wait Time ‐ MRI
All Hospitals are within the Performance Corridor, within Target or within Budget
7 out of 9 Hospitals within Performance Corridor or within Budget/Target
Monitor - 5 out of 9 Hospitals within Performance Corridor and/or within Budget/Target
ATTENTION - 5 or more Hospitals outside the Performance Corridors or not meeting Target/Budget
Page 3 of 13
2008-11 Hospital Service Accounta
2011/12Q2 LHIN Dashboard - ED/ALC
CENTRAL EAST LOCAL HEALTH INTEG
90th Percentile ER LOS for Admitted Patients
CMH
RMH
PRHC
HHHSH
HHHSM
NHH
LHCO
LHCP
LHCB
90th Percentile ER LOS for Non‐Admitted Pati
RVHSC
RVHSA
TSHG
TSHB
CMH
RMH
PRHC
% Above/Below Performance Standard
90th Percentile ER LOS for Admitted Patients
CMH
RMH
PRHC
HHHSH
HHHSM
NHH
LHCO
LHCP
LHCB
RVHSC
RVHSA
TSHG
TSHB
CMH
RMH
PRHC
HHHSH
HHHSM
NHH
LHCO
LHCP
RMH
PRHC
HHHSH
HHHSM
NHH
LHCO
LHCP
LHCP
LH
HHHSH
HHHSM
NHH
LHCO
LHCP
LH
Repeat Unplanned Emergency Visits within
LHCB
RVHSC
RVHSA
TSHG
TSHB
CMH
RMH
PRHC
% Above/Below Performance Standard
ALC ‐ LTC Volume
CMH
LHCO
All but four hospitals are already meeting their targets. Of these 4,
and NHH and RVC are performing below the Provincial target of 7 h
is implementing a corporate-wide improvement plan that is expecte
P4R-designated hospitals are implementing various initiatives, inclu
programs at LHC and RVHS. These initiatives are expected to impr
cohorts.
ALC ‐ LTC Volume
PRHC
NHH
Performance Comments [ER LOS - Non Admitted - Complex
Dashboard
ost hospitals are meeting their targets. The 2 worst performers, LHO and RVAP, while not meeting
eir targets, have improved over last year's baseline. RVAP is working on strategies to right-size bed
ap and increase inpatient capacity. LHC will be piloting a CDU at LHB site. The expected impact of
CDU is a reduction in avoidable inpatient admissions which will contribute to a decrease in ALCsignated patients. This will result in an increase in available inpatient beds. It is expected that they
l both approach their targets by March. The only hospital that has worsened is NHH which
mains one of the best performing hospitals in the LHIN and in the Province when compared against
andard rather than against their own previous performance.
RMH
HHHSM
% Above/Below Performance Stan
90th Percentile ER LOS for Non‐Admitted Pati
erformance Comments [ER LOS - Admitted]
CMH
HHHSH
LHCB
HHHSH
HHHSM
NHH
LHCO
LHCP
LH
% Above/Below Performance Stand
Repeat Unplanned Emergency Visits within RVHSC
erformance Comments [ALC - LTC Volume]
RVHSA
TSHG
TSHB
CMH
RMH
PRHC
HHHSH
HHHSM
NHH
LHCO
LHCP
LH
Performance Comments [Repeat Unplanned Emergency Vis
within 30 days - MH]
Dashboard
BD
TBD
\
Readmission within 30 days for Selected CMGs ‐ CMG 1
CMH
RMH
PRHC
HHHSH
HHHSM
NHH
LHCO
LHCP
LHCB
RVHSC
Readmission within 30 days for Selected CM
RVHSA
TSHG
TSHB
CMH
RMH
PRHC
HHHSH
HHHSM
NHH
LHCO
LHCP
L
2008-12 Hospital Service Accountability Agreement
2011/12 Q2 LHIN Dashboard - Financial/Volume
CENTRAL EAST LOCAL HEALTH INTEGRATION NETWORK
CMH
RMH
PRHC
HHHS
NHH
Total Weighted Cases (Inpatient & Day Surgery)
Current Ratio
Total Margin
LHC
RVHS
TSH
OSMHS
CMH
RMH
PRHC
HHHS
NHH
LHC
RVHS
TSH
OSMHS
CMH
PRHC
HHHS
NHH
LHC
RVHS
TSH
OSMHS
% Above/Below Performance Standard
Total Weighted Cases (Inpatient & Day Surgery)
% Above/Below Performance Standard
Current Ratio
% Surplus/Deficit of LHIN Base Allocation
RMH
x
CMH
RMH
PRHC
HHHS
NHH
P f
C
t [YE T
t l
Performance
Comments
Total
Margin]
LHC
RVHS
TSH
OSMHS
Dashboard
All CE LHIN hospitals have reported in their forecast to
balance at 2011/12 YE.
CMH
RMH
PRHC
HHHS
NHH
Performance
P
f
C
Comments
t [C
[Currentt
Ratio]
LHC
RVHS
TSH
OSMHS
Dashboard
CMH
RMH
PRHC
HHHS
NHH
Performance
P
f
C
Comments
t [T
[Total
t l Wtd
Cases]
LHC
RVHS
TSH
OSMHS
Dashboard
A hospital's Current Ratio is an indicator of the financial health
Total weighted cases (Inpatient & Day Surgery) are OR
of the organization. This measure indicates a Hospital's ability
Cases with weights applied (e.g. case-mix, resource
to currently and prospectively sustain their organization based
utilization, etc.).
on their "financial holdings or assets".
All CE LHIN hospitals have reported in their forecast to be
8 out of 9 CE LHIN hospitals have reported in their forecast to
within their H-SAA corridors for Total Weighted Cases
be within their H-SAA corridors except CMH which is lower by
(Inpatient & Day surgery) at 2011/12 YE.
0.04 (not material).
Legend: Hospitals with Performance outcomes outside the specified Performance Corridors or not within Budget/Target, further investigation is recommended.
***Note: For those Hospitals who did not meet their Target, above/below calculation is applied to their indicator-specific Lower Performance Corridors for each respective organization
|| Status || Status || Status || Status -
All Hospitals are within the Performance Corridor, within Target or within Budget
7 out of 9 Hospitals within Performance Corridor or within Budget/Target
Monitor - 5 out of 9 Hospitals within Performance Corridor and/or within Budget/Target
ATTENTION - 5 or more Hospitals outside the Performance Corridors or not meeting Target/Budget
Page 5 of 13
2008-12 Hospital Service Accountability Agreement
2011/12 Q2 LHIN Dashboard - Volume
CENTRAL EAST LOCAL HEALTH INTEGRATION NETWORK
CMH
RMH
PRHC
HHHS
NHH
LHC
RVHS
TSH
OSMHS
% Above/Below Performance Standard
Mental Health Patient Days [PD]
CMH
RMH
PRHC
HHHS
Performance Commentary [MH PD]
NHH
LHC
RVHS
Ambulatory Care Visits [excl. ER]
CCC Weighted Patient Days & Rehab [PD]
Mental Health Patient Days [PD]
CCC Weighted Patient Days
Rehab [PD]
CMH
OSMHS
Dashboard
This indicator measures the MH Patient days within a given
reporting period (regardless of bed designation).
CCC Weighted Patient Days
Performance Comments [Rehab, CCC Wtd
PD]
Rehab [PD]
Dashboard
PRHC
HHHS
NHH
LHC
RVHS
TSH
OSMHS
TSH
OSMHS
% Above/Below Performance Standard
Ambulatory Care Visits [excl. ER]
% Above/Below Performance Standard
CCC Weighted Patient Days & Rehab [PD]
TSH
RMH
CMH
RMH
PRHC
HHHS
NHH
Performance Comments [Amb. Care Visits]
LHC
RVHS
Dashboard
This indicators measures Rehab Patient Days & CCC Weighted
Patient days. 5 Hospitals within CE LHIN currently provide
Total Outpatient visits (excluding Day/Night Care Surgical
CCC services (RMH, PRHC, NHH, LHC & RVHS). 6 Hospitals
Procedures OR/PARR & Endoscopy) within a given reporting
provide Rehab Services (RMH, PRHC, NHH, LHC, RVHS &
period.
TSH).
All CE LHIN hospitals have reported in their forecast to be
All CE LHIN hospitals have reported in their forecast to be
within their H-SAA corridors for Mental Health Patient Days at All CE LHIN hospitals have reported in their forecast to be
within their H-SAA corridors for Ambulatory Care Visits
2011/12 YE.
within their H-SAA corridors for CCC Weighted Patient Days &
(exclude ER) at 2011/12 YE.
Rehab Patient Days at 2011/12 YE.
Legend: Hospitals with Performance outcomes outside the specified Performance Corridors or not within Budget/Target, further investigation is recommended.
***Note: For those Hospitals who did not meet their Target, above/below calculation is applied to their indicator-specific Lower Performance Corridors for each respective organization
|| Status || Status || Status || Status -
All Hospitals are within the Performance Corridor, within Target or within Budget
7 out of 9 Hospitals within Performance Corridor or within Budget/Target
Monitor - 5 out of 9 Hospitals within Performance Corridor and/or within Budget/Target
ATTENTION - 5 or more Hospitals outside the Performance Corridors or not meeting Target/Budget
Page 6 of 13
2008-12 Hospital Service Accountability Agreement
2011/12 Q2 LHIN Dashboard - Surgical & DI Wait Times
CENTRAL EAST LOCAL HEALTH INTEGRATION NETWORK
90th Percentile Wait Time ‐ Cancer Surgery CMH
RMH
PRHC
HHHS
NHH
LHC
RVHS
90th Percentile Wait Time ‐ Cataract Surgery TSH
CMH
RMH
PRHC
HHHS
Performance Comments [Cancer]
NHH
LHC
PRHC
HHHS
NHH
LHC
RVHS
TSH
CMH
% Above/Below Performance Standard
Cataract Surgery % Above/Below Performance Standard
Cancer Surgery CMH
RMH
90th Percentile Wait Time ‐ Hip Relacement
RVHS
TSH
Dashboard
5 out of 6 CE LHIN hospitals are within their H-SAA corridors in
Q2, with TSH above its H-SAA upper corridor by 2 days (not
material).
CE LHIN plans to invite Cancer Care Ontario to the Wait Times
Strategy Working Group meeting in the near future to discuss
cancer surgery wait times targets.
CMH
RMH
PRHC
HHHS
Performance Comments [Cataracts]
NHH
LHC
RMH
PRHC
HHHS
NHH
LHC
RVHS
TSH
% Above/Below Performance Standard
Hip Relacement
RVHS
TSH
Dashboard
5 out of 6 CE LHIN hospitals are within their H-SAA corridors in
Q2, with PRHC above its H-SAA upper corridor by 16 days,
which is mainly due to a data quality issue identified at one of
the ophthalmologist’s offices.
CMH
RMH
PRHC
HHHS
NHH
Performance Comments [Hips]
LHC
RVHS
TSH
Dashboard
5 out of 6 CE LHIN hospitals are within their H-SAA corridors in
Q2, with RVHS above its H-SAA upper corridor by 104 days,
which is mainly due to the unavailability of one orthopeadic
surgeon.
When the data quality issue is addressed and a new surgeon is
hired in November, PRHC expects to lower its cataract wait
RVHS has resolved this staffing issue in October, and expects to
times and meet the H-SAA target by 2011/12 Q4. In addition,
lower its hips replacement wait times and meet the H-SAA
CE LHIN is funding 801 more procedures at TSH, which will help target by 2011/12 Q4.
with wait times reduction in the CE LHIN.
***Note: For those Hospitals who did not meet their Target, above/below calculation is applied to their indicator-specific Lower Performance Corridors for each respective organization
|| Status || Status || Status || Status -
All Hospitals are within the Performance Corridor, within Target or within Budget
7 out of 9 Hospitals within Performance Corridor or within Budget/Target
Monitor - 5 out of 9 Hospitals within Performance Corridor and/or within Budget/Target
ATTENTION - 5 or more Hospitals outside the Performance Corridors or not meeting Target/Budget
Page 7 of 13
2008-12 Hospital Service Accountability Agreement
2011/12 Q2 LHIN Dashboard - Surgical & DI Wait Times
CENTRAL EAST LOCAL HEALTH INTEGRATION NETWORK
CMH
RMH
PRHC
HHHS
NHH
LHC
RVHS
TSH
CMH
% Above/Below Performance Standard
90th Percentile Wait Time ‐ Knee Relacement
CMH
RMH
PRHC
HHHS
Performance Comments [Knees]
NHH
LHC
RVHS
90th Percentile Wait Time ‐ MRI
90th Percentile Wait Time ‐ CT
90th Percentile Wait Time ‐ Knee Relacement
RMH
PRHC
HHHS
NHH
LHC
RVHS
TSH
CMH
% Above/Below Performance Standard
90th Percentile Wait Time ‐ CT
TSH
Dashboard
CMH
RMH
PRHC
Performance Comments [CT]
HHHS
NHH
LHC
RMH
PRHC
HHHS
NHH
LHC
RVHS
TSH
% Above/Below Performance Standard
90th Percentile Wait Time ‐ MRI
RVHS
Dashboard
TSH
CMH
RMH
PRHC
HHHS
NHH
Performance Comments [MRI]
LHC
RVHS
TSH
Dashboard
4 out of 6 CE LHIN hospitals are within their H-SAA corridors in
Q2, with NHH above its upper corridor by 3 days (not material)
and LHC by 51 days mainly due to its aged MRI machine and
the inreasing demand caused by referrals.
With the aged MRI machine replaced in August 2011 and
additional $285k UPF funding from the CE LHIN to help LHC
maintain the same level of funded volumes as prior year, LHC
expects to lower its MRI wait times and meet the H-SAA target
by 2011/12 Q4. In addition, CE LHIN is providing additional
funding up to identified hospital capacity as a means to improve
MRI performance in Q4.
Legend: Hospitals with Performance outcomes outside the specified Performance Corridors or not within Budget/Target, further investigation is recommended.
All CE LHIN hospitals are within their knee replacement wait
times H-SAA corridor in Q2.
All CE LHIN hospitals are within their CT wait times H-SAA
corridors in Q2.
***Note: For those Hospitals who did not meet their Target, above/below calculation is applied to their indicator-specific Lower Performance Corridors for each respective organization
|| Status || Status || Status || Status -
All Hospitals are within the Performance Corridor, within Target or within Budget
7 out of 9 Hospitals within Performance Corridor or within Budget/Target
Monitor - 5 out of 9 Hospitals within Performance Corridor and/or within Budget/Target
ATTENTION - 5 or more Hospitals outside the Performance Corridors or not meeting Target/Budget
Page 8 of 13
2008-11 Hospital Service Accountability Agreement
2011/12Q2 LHIN Dashboard - ED
CENTRAL EAST LOCAL HEALTH INTEGRATION NETWORK
CMH
RMH
PRHC
HHHSH
HHHSM
NHH
LHCP
LHCB
RVHSC
RVHSA
TSHG
TSHB
LHCO
CMH
RMH
PRHC
HHHSH
HHHSM
NHH
LHCP
LHCB
RVHSC
RVHSA
TSHG
TSHB
RMH
PRHC
HHHSH
HHHSM
NHH
LHCP
LHCB
RVHSC
RVHSA
TSHG
TSHB
Performance Comments [ER LOSAdmitted]
LHCO
% Above/Below Performance Standard
90th Percentile ER LOS for Non‐Admitted Patients ‐
Complex
% Above/Below Performance Standard
90th Percentile ER LOS for Admitted Patients
CMH
90th Percentile ER LOS for Non‐Admitted Patients ‐
Minor
90th Percentile ER LOS for Non‐Admitted Patients ‐
Complex
90th Percentile ER LOS for Admitted Patients
LHCO
Dashboard
Most hospitals are meeting their targets. The 2 worst
performers, LHO and RVAP, while not meeting their targets,
have improved over last year's baseline. RVAP is working on
strategies to right-size bed map and increase inpatient capacity.
LHC will be piloting a CDU at LHB site. The expected impact of
a CDU is a reduction in avoidable inpatient admissions which will
contribute to a decrease in ALC-designated patients. This will
result in an increase in available inpatient beds. It is expected
that they will both approach their targets by March. The only
hospital that has worsened is NHH which remains one of the
best performing hospitals in the LHIN and in the Province when
compared against standard rather than against their own
previous performance.
CMH
RMH
PRHC
HHHSH
HHHSM
NHH
LHCP
LHCB
RVHSC
RVHSA
TSHG
TSHB
Performance Comments [ER LOS-NonAdmitted-Complex]
CMH
RMH
PRHC
HHHSH
HHHSM
NHH
LHCP
LHCB
RVHSC
RVHSA
TSHG
TSHB
LHCO
% Above/Below Performance Standard
90th Percentile ER LOS for Non‐Admitted Patients ‐
Minor
LHCO
Dashboard
All but four hospitals are already meeting their targets. Of these
4, PRHC has improved over last year and NHH and RVC are
performing below the Provincial target of 7 hours. The
remaining hospital, LHO, is implementing a corporate-wide
improvement plan that is expected to improve performance in
Q3. P4R-designated hospitals are implementing various
initiatives, including MOHLTC-sponsored ED-PIP programs at
LHC and RVHS. These initiatives are expected to improve
performance in all patient cohorts.
CMH
RMH
PRHC
HHHSH
HHHSM
NHH
LHCP
LHCB
RVHSC
RVHSA
TSHG
TSHB
Performance Comments [ER LOS-NonAdmitted-Minor]
LHCO
Dashboard
Most Central East LHIN hospitals are struggling with this
measure. The Provincial standard for non-admitted CTAS IV-V
patients is 4 hours and only 3 hospitals, LHB, LHPP and RVAP,
are consistently meeting this standard. The highest ED LOS in
the LHIN for this patient cohort is LHO at 5.1 hours. P4Rdesignated hospitals are implementing initiatives to decrease
time to Physician Initial Assessment (PIA), the strongest
contributor to length of stay for low acuity patients. Hospitals
are expected to achieve or approach targets by March.
Legend: Hospitals with Performance outcomes outside the specified Performance Corridors or not within Budget/Target, further investigation is recommended.
***Note: For those Hospitals who did not meet their Target, above/below calculation is applied to their indicator-specific Lower Performance Corridors for each respective organization
|| Status || Status || Status || Status -
All Hospitals are within the Performance Corridor, within Target or within Budget
7 out of 9 Hospitals within Performance Corridor or within Budget/Target
Monitor - 5 out of 9 Hospitals within Performance Corridor and/or within Budget/Target
ATTENTION - 5 or more Hospitals outside the Performance Corridors or not meeting Target/Budget
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H‐SAA Indicator Name
Financial Year End Total Margin
Current Ratio
Volumes Total Wtd Cases (Inpatient & Day Surgery)
Mental Health Patient Days
Rehab Patient Days
CCC Weighted Patient Days
Ambulatory Visits [excl. ER]
H‐SAA Indicator Definition
Corporate revenues that are over/under corporate expenses (certain exclusions apply to both such as Interdepartmental recoveries/expenses, etc to either numerator/denominator). Measure of liquidity that denotes an organization's capacity to meet their short‐term obligations
Total weighted cases (Inpatient & Day Surgery Services) are Operating Room (OR) Cases with weights applied (e.g. case‐mix groups, resource utilization, etc.)
Number of Mental Health patient days reported within a given reporting period (number of days a patient is admitted and occupying a Mental Health bed within a designated unit before discharge from the organization).
Number of Rehabilitation patient days reported within a given reporting period (number of days a patient is admitted and occupying a Rehabilitation bed within a designated unit before discharge from the organization).
Number of Complex Continuing Care 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.
Wait Time Services ‐ 90th Percentile Wait Times
Cancer Surgeries
Cataract Surgeries
Total Hip & Knee Replacements
Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)
The time between a patient’s and surgeon’s decision to proceed with surgery, and the time the procedure is conducted. The 90th percentile is the point at which 90% of the patients received their treatment while the other 10% waited longer.
The time between a patient’s and surgeon’s decision to proceed with surgery, and the time the procedure is conducted. The 90th percentile is the point at which 90% of the patients received their treatment while the other 10% waited longer.
The time between a patient’s and surgeon’s decision to proceed with surgery, and the time the procedure is conducted. The 90th percentile is the point at which 90% of the patients received their treatment while the other 10% 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’.
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’.
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
The total emergency room (ER) length of stay (LOS) where 9 out of 10 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 10 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 10 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).
Repeat Unplanned Emergency Visits within 30 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 Repeat Unplanned Emergency Visits Within 30 Days that occurs in any Ontario hospital within 30 days. The ‘index’ visit must be for a mental health condition; however, the repeat visit can be for any diagnosis within ICD‐10‐CA Chapter 5 (i.e. either a mental for Mental Health Conditions
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 Repeat Unplanned Emergency Visits Within 30 Days that occurs in any Ontario hospital within 30 days. The ‘index’ visit must be for a substance abuse condition however, the repeat visit can be for any diagnosis within ICD‐10‐CA Chapter 5 (i.e. either a for Substance Abuse Conditions
mental health OR substance abuse condition).
Repeat Unplanned Emergency Visits within 30 days
Readmission Within 30 Days For Selected CMGs
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 40): 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; 10. Cirrhosis/Alcoholic Hepatitis; 11. Liver Disease except Cirrhosis/Malignancy; 12. Disorder of Pancreas except Malignancy; 13. Disorder of Biliary Track
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