1

Board Monitor – Quarterly ReportQuality and Performance Indicators

December 2007

2

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 12

Goal #3 - We have a healthy work environment 18

Goal #4 – We have a sound financial base to sustain our mission and achieve our vision 22

Goal #5 –We create a sustainable and aligned system through action and leadership 26

3

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

HumanCapitalInformationCapital

Organization CapitalCulture Leadership Corporate Change

& Alignment Teamwork

Internal Process Perspective

Patient, Family, Customer Perspective

Acce

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Car

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Qual

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itiat

ives

Oper

atio

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Perfo

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Heal

thy

Peop

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nd

Envi

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Syst

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& L

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Fiduciary Perspective

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The Hamilton Health Sciences (HHS) Board Monitor provides a quarterly report on Key Quality and Performance Indicators. The latter have been identified by the Board of Trustees to reflect the Hospital’s five Strategic Goals. HHS has defined priorities to achieve these strategic goals:

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.

The Board Monitor is organized by Strategic Goals and the Key Quality and Performance Indicators (KPI) reflect the performance within the Goals. Many of the Key Performance Indicators have benchmarks or targets assigned to them based on either industry rates, best practice and/or LHIN/Ministry targets.

Introduction

5

Strategic Goal #1

We meet or exceed our communities’ expectations

Indicators:• Emergency Department Wait Times By Site – Quality Indicator• Target volumes/actuals – Performance Indicator• ALC Rates – Quality Indicator• Wait Time Strategy by Service – Quality Indicator

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Emergency Department Wait Times By Triage LevelQuality Indicator

Source: HHS ADT/ED Meditech System HAPS Indicator

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

CTAS Codes:Triage 1: ResuscitationTriage 2: EmergentTriage 3: UrgentTriage 4: Less UrgentTriage 5: Non 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

10 .0 0

12 .0 0

14 .0 0

D e c - 0 6 J a n - 0 7 F e b - 0 7 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

Ho

ur

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

E m e r g e n c y D e p t W a i t T Im 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 4 ,5

2 .0 0

2 .5 0

3 .0 0

3 .5 0

4 .0 0

4 .5 0

D e c - 0 6 J a n - 0 7 F e b - 0 7 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

Ho

ur

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

7

Target Volumes/ActualsPerformance Indicator

Source: HHS Data Repository HAPS Indicators

H A P S V o l u m e I n d i c a t o r s D e f i n i t i o nA p r - D e c 2 0 0 7

A p r - D e c 2 0 0 7 H H S B u d g e t V a r ia n c e H H S B u d g e t M O H T a r g e t * M O H C o r r i d o r *

W e ig h t e d C a s e s C IH I D A D P A C 1 0 R IW a n d Q u a l i fy i n g S D S 5 7 , 8 6 3 5 6 , 1 2 7 1 , 7 3 6 6 9 , 6 3 0 7 0 , 9 0 1 6 7 , 5 4 1 - 7 1 , 7 1 9

A c u t e S e p a r a t i o n s 2 8 , 7 7 7 2 7 , 8 2 1 9 5 6 3 7 , 1 1 4 3 4 , 0 8 8 3 3 , 9 7 0 - 3 6 , 8 0 0A c u t e P a t i e n t D a y s 2 0 2 , 1 6 3 2 0 0 , 0 0 8 2 , 1 5 5 2 6 6 , 3 4 2 2 6 6 , 9 1 8 2 5 3 , 2 0 9 - 2 6 8 , 8 7 1R e h a b i l i t a t i o n S e p a r a t i o n s R e h a b i l i t a t i o n 9 5 8 1 , 1 6 6 - 2 0 8 1 , 5 5 6 n o t a r g e t n o t a r g e tR e h a b i l i t a t i o n P a t i e n t D a y s R e h a b i l i t a t i o n 3 0 , 6 4 5 3 4 , 3 1 6 - 3 , 6 7 1 4 5 , 6 7 3 4 3 , 4 9 2 4 2 , 7 4 2 <

E m e r g e n c y V i s i t s A l l E D V i s i t s 8 2 , 1 9 1 8 1 , 8 9 9 2 9 2 1 0 9 , 0 0 0 1 0 9 , 7 9 4 1 0 6 , 5 6 0 <

In p a t i e n t S u r g e r y C a s e s D o n e i n M a i n O R 1 0 , 6 4 1 1 0 , 9 3 3 - 2 9 2 1 4 , 7 3 9 n o t a r g e t n o t a r g e tO u t p a t i e n t S u r g e ry C a s e s D o n e i n M a i n O R 8 , 7 6 0 8 , 6 0 6 1 5 4 1 1 , 5 4 5O u t p a t i e n t S u r g e ry C a s e s S D S P r o c e d u r e R m s 3 , 9 2 9 3 , 7 5 7 1 7 2 5 , 0 0 0

A m b u la t o r y C l i n i c s e x c l E D , D / N a n d S D S 5 1 6 , 6 1 3 4 9 7 , 6 9 0 1 8 , 9 2 3 6 6 0 , 0 0 0 6 0 1 , 6 0 0 6 0 1 , 6 0 0 <

* M O H T a r g e t b a s e d o n 3 y e a r r o l l i n g a ve r a g e a n n u a l f i g u r e a n d c o r r i d o r s e t a s a % a b o ve / b e lo w t h a t t a r g e t . T h e c o r r i d o r va r i e s d e p e n d i n g o n i n d i c a t o r ( s e e H A P S d e t a i l t e c h n i c a l s p e c i f i c a t i o n s )N o t e : C IH I d a t a i s e s t im a t e d fo r 2 0 0 7 / 0 8 y t d S e p t e m b e r

R e d : P r o j e c t e d o u t s id e o f M O H C o r r i d o r a n d w i l l r e s u l t i n fo r m a l r e v i e wY e l l o w a n d G r e e n : W i t h i n o r b e t t e r t h a n M O H C o r r i d o r w i t h n o fo r m a l r e v i e w

D is c h a r g e / D e a t h s e x c l b a s s i n e t t e s

1 2 , 4 9 1 1 1 , 8 5 7 <

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ALC Patient TrendsQuality Indicator

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 %

D e c - 0 6 J a n - 0 7 F e b - 0 7 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

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

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

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

C o m p le x C a r e P a ll ia 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

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Wait Time Information Strategy: Wait Times - Quality Indicator

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 - Quality Indicator

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 - Quality Indicator

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

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

% o f P a t i e n t s S e e n w i t h i n 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 im 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 ( T a r g e t 1 4 d a y s ) 5 9 . 3 % 6 2 . 3 % 1 3 1 2R e a d y t o T r e a t t o T r e a t m e n t ( a l l U r g e n c y c a t e g o r i e s ) 5 3 . 0 % 5 6 . 3 % 1 3 9

N o v e m b e r 2 0 0 7

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

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

% o f P a t i e n t s S e e n w i t h i n 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 ( T a r g e t 1 4 d a y s ) 4 5 . 2 % 4 0 . 1 % 1 6 1 8

R e a d y t o T r e a t t o T r e a t m e n t ( a l l U r g e n c y c a t e g o r i e s ) 7 8 . 9 % 7 0 . 8 % 2 5

N o v e m b e r 2 0 0 7

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Indicators: •Infection Rates – Quality Indicator•Hospital Standardized Mortality Rates (HSMR) – Quality Indicator•Dollars Spent on Research – Performance Indicator

Strategic Goal #2

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

13

Infections Rates – Nosocomial VRERate per 1000 Patient Days

Quality IndicatorVRE-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.

00 .20 .40 .60 .8

11 .21 .41 .61 .8

22 .22 .42 .6

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

14

Infections Rates – Nosocomial C-DifficileRate per 1000 Patient Days

Quality IndicatorC 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 .2

0 .4

0 .6

0 .8

1

1 .2

1 .4

1 .6

1 .8

2

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

15

Infections Rates – Nosocomial MRSARate per 1000 Patient Days

Quality IndicatorMRSA - 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

00 .20 .40 .60 .8

11 .21 .41 .61 .8

22 .22 .42 .62 .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

16

Hospital Standardized Mortality Ratio (HSMR)Quality Indicator

7 8

1 1 0

6 9

8 68 1

1 1 4

7 7

9 19 6

1 1 0

7 9

9 5

6 5

1 1 0

8 3 8 3

01 02 03 04 05 06 07 08 09 0

1 0 01 1 01 2 0

1 s t Q t r F Y 0 6 / 0 7 2 n d Q t r F Y 0 6 / 0 7 3 r d Q t r F Y 0 6 / 0 7 4 t h Q t r F Y 0 6 / 0 7

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 not available until February 2008

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.

Board Monitor 17

Research Expenditures

Presentation Pending – working with Research to determinean appropriate indicator

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Indicators:• Vacancy Counts – Performance Indicator• External Staff Turnover – Performance Indicator•Absenteeism Rates- Performance Indicator

Strategic Goal #3

We have a healthy work environment

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Vacancy CountsAs at end of month based on

unfilled postingsPerformance Indicator

Source: HRMS Peoplesoft Recruitment Module – based on number days the recruitment request has been posted

This indicator is a work in progress – focus for the future will be on critical positions and the time to fill them.

A p r i l 0 7 M a y 0 7 J u n e 0 7 J u l y 0 7 A u g u s t 0 7 S e p t 0 7 O c t 0 7 N o v 0 7 D e c 0 7C U P E 3 5 2 2 2 2 3 2 2 2 2 3 1 9 2 9 3 6O N A 5 9 4 9 4 2 3 9 2 8 2 7 3 3 2 5 2 5O P S E U 9 4 4 6 3 6 6 3 4N o n - U n io n 2 0 1 7 9 1 2 1 5 1 3 1 4 1 0 1 6

6 0 - 9 0 d a y s

A p r i l 0 7 M a y 0 7 J u n e 0 7 J u l y 0 7 A u g u s t 0 7 S e p t 0 7 O c t 0 7 N o v 0 7 D e c 0 7C U P E 4 2 5 0 4 9 3 8 4 4 4 3 4 0 3 0 4 2O N A 4 3 6 1 7 1 8 9 7 9 5 5 3 9 4 6 4 9O P S E U 7 6 5 9 6 8 1 2 1 1 1 0N o n - U n io n 2 6 3 3 3 4 2 5 1 7 2 0 2 1 2 2 1 9

> 9 0 d a y s

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External Turnover RatesPerformance Indicator

0 .5 6 %

0 .4 7 %

0 .6 4 % 0 .6 4 %0 .5 7 %

0 .4 7 %0 .5 3 %

0 .6 0 %

0 .7 1 %

0 .5 0 %

1 .2 7 %

0 .6 3 %

0 .8 5 %

0 .0 0 %

0 .2 0 %

0 .4 0 %

0 .6 0 %

0 .8 0 %

1 .0 0 %

1 .2 0 %

1 .4 0 %

1 .6 0 %

1 .8 0 %

2 .0 0 %

D e c - 0 6 J a n - 0 7 F e b - 0 7 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

External: Number of staff who have left the organization over average employee count per month.

Source: HRMS Peoplesoft

21

Absenteeism RatePerformance Indicator

Sick Hours Paid as a Percentage of Total Paid Hours

Source: Peoplesoft Time and Labour Payroll

This indicator is a HAPS indicator and is a percentage of sick time hours to total earned hours

0 . 0 0 %

0 . 5 0 %

1 . 0 0 %

1 . 5 0 %

2 . 0 0 %

2 . 5 0 %

3 . 0 0 %

3 . 5 0 %

4 . 0 0 %

4 . 5 0 %

5 . 0 0 %

5 . 5 0 %

6 . 0 0 %

D e c - 0 6 J a n - 0 7 F e b - 0 7 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

H H S H H S T a r g e t

22

Indicators:•Total Margin and Current Ratio – Performance Indicator•Cost per Weighted Case Trend – Performance Indicator•Capital Projects (TBD) – Performance Indicator

Strategic Goal #4

We have a sound financial base to sustain our mission and achieve our vision

23

Total Margin and Current RatioPerformance Indicator

F i s c a l 0 5 / 0 6 F i s c a l 0 6 / 0 7 Y T D D e c 0 7 P r o j e c t i o n 0 7 / 0 8H H S C u r r e n t R a t i o 1 . 1 1 1 . 2 5 1 . 2 5 1 . 1 7M i n i s t r y T a r g e t 0 . 8 0 0 . 8 0 0 . 8 0 0 . 8 0

T o t a l M a r g in 0 . 1 8 % 0 . 2 1 % 0 . 1 7 % 0 . 3 1 %M i n i s t r y T a r g e t 0 . 0 0 0 . 0 0 0 . 0 0 0 . 0 0

Summary: Calculated for HAPS definition: Current Assets/Current Liabilities (excludes deferred contributions) without adjustments for timing of MOH payments. Total Margin is Consolidated Total Surplus(Deficit)/Total Revenues (before Building depreciation, net of amortized grants and excluding recoveries).

24

Cost per Weighted Case TrendPerformance Indicator

6 ,1 3 45 ,5 4 6

4 ,9 7 9

5 ,5 3 95 ,8 7 5

5 ,3 5 95 ,1 7 8

4 ,9 7 9

0

1 , 0 0 0

2 , 0 0 0

3 , 0 0 0

4 , 0 0 0

5 , 0 0 0

6 , 0 0 0

7 , 0 0 0

8 , 0 0 0

2 0 0 3 / 0 4 2 0 0 4 / 0 5 2 0 0 5 / 0 6 2 0 0 6 / 0 7

A c t u a l I n fl a t i o n L i n e

Source: MOHLTC OCDM Methodology. The numerator is based on Acute Inpatient and SDS costs and the denominator isAcute Inpatient and Qualifying SDS PAC10 Weighted Cases. Trendline is 4% inflation

25

Capital Projects

Work in Progress

26

Strategic Goal #5

We create a sustainable and aligned system through action and leadership

Indicators:•Work in Progress

27