runnymede balanced scorecard€¦ · cdi can spread when individuals come into contact with objects...

Current Period Q2 2014/15Q1 2014/15

7Pain 1% * 0.4%* 4.3% 7.1% 8

10Worsening Pain 4.9% * 3.6%* 7.5% 9.0% 9Medication Reconcilliation on Admission 100% 100% 100% n/a

†

30

^ Significant Corrections submitted to CIHI, results pending

RHC Strategic Plan requirement

MOHLTC requirement

Value is based on a preliminary estimate.

Relationships

Green Green indicates that the performance indicator is on track to meet or exceed the annual target/benchmark.

Red Red indicates that the performance indicator is not on track to meet the annual target/banchmark and has not improved over the prior reporting period.

Yellow Yellow indicates that the current performance is not on track to meet the annual target/benchmark, but has improved over the prior period.

n/a

Indicator values reflect most up-to-date data available (Q1 2014/15). *

Quality Improvement Plan requirement

Indicator Classification

2 n/a

321,989 n/a 31

4 n/a

34100% n/a39,976 n/a

n/a 29

33Measure of Website Traffic (visits)

240 522# of Presentations/Publications 4 4

22,921 11,142% of Corporate Departmental Processes Transitioned to Electronic 33% 0%

# of Student Days

25

2324

2756 180/yr n/a

Student Satisfaction Scores 100% 80% 75%

28# of Board Committee Appointments 5 5 5# of External Committee Appointments 4 1

22# of Annual ED Transfers 2.47 2.17 1.94 n/a

1.48 1.00 1.27n/a1 3

Average Length of Stay SJHC LTLD Rehab Patients 50.4

Current Ratio 1.65

# of LTLD patients admitted from SJHC 5756 69 days

9.2% 9.2%

2021

17.1%

RUGs Weighted Patient Days (RWPD) 20,863

15.0%4.49%Total Margin 6.68%

20,800 † 87,047 n/a

0.00% 3.70%% of Non-MOHLTC Revenue 16.5% 16.5%

# of new Partnerships 1

18100% 100% n/a

Turnover Rate 3.83% 3.93% 16

# of Critical Patient Incidents 0

% of Annual Budget Allocated to Staff Education 1.24% 1.19% 1.75% 1.75 17

14Lost Time Due To Injury 0.47 0.98 1.66 1.66 15

% of Unresolved Patient Complaints 0% 0% 0% n/a 13

Hand Hygiene Compliance 86.0% 90.0% 91% 80.5% 3ALC Rate 3.1% * 4.9% 6.9% 10.1%

1211Patient Satisfaction - Overall Quality of Care Rating 83.3%

Strategic Direction

Indicator Classification Performance Indicator

Current Period

Urinary Tract Infections 0.7% * 1%* 2.8% 4.5%

0.4%*5.6% *

1.0% 2.0%11.5%

0.4% *Falls

Annual Rate of Clostridium Difficile Infection

Page

0.35 2

November 6, 2014

Previous Period

4

80.4%87.0%

Runnymede Balanced ScorecardPrevious Period Target Benchmark

0.08 0.12 0.09

96.2%82.8%91.9%

81.7%93.1%Family/Visitor Satisfaction - Overall Quality of Care Rating

Growth

26

3.6% 61.3%*Has new Pressure Ulcer 5

Electronic Medical Record Adoption Model (EMRAM) Score 0.005 0.005 1.000 1.13 19% of IT Projects Completed on Budget 100%

Operational Excellence

0 0 n/a

- 2 -

Definition:

Significance:Ontario, MOHLTC

Target:

Benchmark:

Number of patients newly diagnosed with hospital-acquired Clostridium Difficile Infection (CDI), divided by the number of patient days in that period, multiplied by 1,000.

Clostridium difficile (also C. difficile or C. diff) is a common bacterium that is found in the environment and occurs naturally in some people. When C. difficile damages the bowel and causes diarrhea, it is known as Clostridium difficile-associated Disease (CDI). CDI sometimes occurs when antibiotics are prescribed. Antibiotics work by killing off bacteria – both “bad” and “good” bacteria. When “good” bacteria are killed, C.difficile can grow and release toxins that can damage the bowel and may cause diarrhea. In severe cases, surgery may be needed, and in extreme cases C. difficile may cause death. C. difficile is the most common cause of infectious diarrhea in hospitals and/or long-term care homes.

CDI can spread when individuals come into contact with objects contaminated with the C. difficile bacteria such as toilets or bedpans used by a patient with the disease. Proper and frequent hand hygiene and thorough room cleaning are two ways to minimize the risk of spread.

2013 ( Jan - Dec) provincial average = 0.34. Source: MOHLTC

0.09 / 1000 Patient Days ( Calendar Year)

Annual Rate of Clostridium Difficile InfectionOperational ExcellenceQ2 2014/15

Performance Management Summary Reporting Accountability

IndicatorStrategic Focus AreaTimeframe

Data Source:

Indicator Owner:Reporting Body:

Runnymede's Infection Prevention & Control

Difficile cases)Surveillance data (Line listing of C.

Accreditation Canada, Health QualityInfection Control Practitioner

Reporting Timeline:

Insert Chart/Graph

Calendar Year

Due Date

Current Period (Q2 2014/15)

Previous Period (Q1 2014/15)

Target Indicator Status

CDI Rate

Analysis

0.08 0.12 0.09 Opportunities for improvement

Current StatusLead Date Initiated

Two cases reported for the quarter. Cummulative results for the calendar year are depicted in the graph.

Action Plan

1-Nov-14Quick reference document for clinical staff for common HAIs. Information to include signs and symptoms, specimen information, duration of precautions. PendingApr-14APL- IPAC

CompleteAPL- IPAC Apr-141-Jun-14Make Bristol stool chart available to nursing staff on units and on iConnect.

Collaborate with Communications to make educational module available on iConnect. 1-Jun-14 APL- IPAC Apr-14 Complete

Incorporate Infection Prevention & Control (IPAC) competencies into employee performance evaluations 1-Dec-14 APL-IPAC Sep-14 In Progress

80% of all Clinical staff be educated on Core Competencies-Health Care Provider Controls Education Module (Chain of Transmission and Risk Assesment) 1-Dec-14 APL-IPAC Sep-14 In Progress

Streamline process pertaining to ordering of hygenic bags for commodes for patients on precautions for clostridium difficile 1-Nov-14 APL- IPAC Sep-14 Pending

Review and update hand hygiene auditors' training and educational material 01-Oct-15 APL- IPAC Aug-14 Complete

Trial sporocidal wipes on all patient care units. Rollout sporocidal wipes for patients with Clostridium Difficile infection hospital wide. 1-Jun-14 APL- IPAC May-14 Complete

Target

Marginal

Out of Target

Benchmark

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

2012 2013 2014

CD

I Rat

e

Fiscal Year

Clostridium Difficile Associated Diseases

- 3 -

Definition:

Significance:

Target:91% (January - December 2014)

Benchmark:

Quarterly

Insert Chart/Graph

Data Source:

Indicator Owner:Reporting Body:Reporting Timeline:

Runnymede's Hand Hygiene Compliance Data(Observational Audit Sessions)

MOHLTC, Health Quality OntarioInfection Control Practitioner

Feedback of hand hygiene compliance to staff and continue auditing hand hygiene practices including education to reduce improper glove use 1-Mar-2015 In Progress 1-Feb-14APL- IPAC

Runnymede's hand hygiene rates for Q2 are slighly decreased. During the last two quarters there was a turnover in the IPAC department as well as the change in numbner of observers. Recruitments have been completed with addition of an Infection Control Coordinator; performance is expected to improve.

Action PlanDue Date Lead Date Initiated Current Status

Hand Hygiene ComplianceOperational ExcellenceQ2 2014/15



Hand Hygiene Compliance

Analysis

86.0% 90.0% 91% Opportunities for improvement

The number of times that hand hygiene was performed before initial patient contact divided by the number of observed hand hygiene indications before initial patient contact multiplied by 100.

The single most common way of transferring health care-associated infections (HAIs) in health care settings is on the hands of health care providers. Health care providers move from patient to patient and room to room while providing care and working in the patient environment. This movement provides many opportunities for the transmission of organisms on hands that can cause infections. Proper hand hygiene will protect patients and providers and will reduce the spread of infections and the associated treatment costs, reduce hospital lengths of stay and readmissions, reduce wait times, and prevent deaths (MOHLTC 2011).

2013/2014 provincial average 86.31%. Source: MOHLTC


Previous Period (Q1 2014/15)

TargetJan - Dec 2014 Indicator Status

1-Dec-14 APL-IPAC Sep-14 In Progress

All nursing staff to complete IPAC Core Competencies-Health Care Provider Controls Education Module (Hand Hygiene & Routine Practices)

Incorporate Infection Prevention & Control (IPAC) competencies such as hand hygiene certification & hand care program into employee performance evaluations and new hire managerial checklist

1-Dec-14 APL-IPAC Sep-14 In Progress

Complete Collaborate with Communications to make educational module available on i-connect 1-Jul-2014 APL- IPAC 1-May-14

In Progress

Changing linen and waste disposal work flow to prevent linen/garbage carts from travelling room to room which creates barrier for proper hand hygiene and encourages unnecessary glove use.• Coordinate with interdisciplinary team to improve process. • Each patient room to have own labeled dedicated linen and waste bins.

1-Mar-2015 APL- IPAC 1-Feb-14

Out of Target

Marginal

Target

Benchmark

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

2012 2013 2014

Han

d H

ygie

ne C

ompl

ianc

e

Calendar Year

Hand Hygiene Compliance

- 4 -

Definition:

Quality Improvement Plan Target: 6.9%Benchmark (TC LHIN average for CCC hospitals): 10.1%

Runnymede's ALC rate is better than target and the TC LHIN's average for CCC hospitals. Q2 2014/15 results are expected to be avialable during the last week of November 2014.

ActionsDue Date Lead Date Initiated Current Status

ALC Rate


Previous Period (Q4 2013/14) Target Indicator Status

Analysis

ALC Rate (Inpatient Days) = Total number of ALC days in a given time period divided by Total number of inpatient days in the same time period (Data available from CCO 2 months after quarter end).

Lead Mgr, Allied Health & Pharmacy

Reporting Body:EAC, MAC, Quality Committee, Health Quality Ontario

3.1% 4.9% 6.9% Indicator meets or exceeds performance target

Significance - ALC avoidance has been identified as a strategic priority for our organization, and is part of our Quality Improvement Plan, with a target for the ALC rate of 6.9%. The ALC rate indicator represents an accurate count of total ALC days and total patient days for both open and closed cases in a given month, and therefore provides an accurate picture of ALC performance that can be tracked over time.

Timeframe Q1 2014/15Performance Management Summary Reporting Accountability

Data Source: CCO

Implementation of 2014/15 ALC Avoidance Strategy Mar-15 VP Clinical Programs Apr-14 In Progress

Indicator ALC Rate- Inpatient DaysStrategic Focus Area Operational Excellence

1.0%

3.0%

5.0%

7.0%

9.0%

11.0%

13.0%

15.0%

Q3 2012Q4 2012Q1 2013Q2 2013Q3 2013Q4 2013Q1 2014

Fiscal Year

ALC Rate

Target

ALC Rate

TC LHIN ALC Rate

- 5 -

Definition:

Quality Improvement Plan Target: 1.0%Benchmark (TC LHIN average - Q1 2014): 1.9%

Revise the wound care audit tool Aug-14 Advance Practice Leader (APL) Nursing Aug-14 Complete

Complete root cause analysis of all new stage 2-4 wounds and identify opportunities for improvement Aug-14 Advanced Practice Leader (APL) Nursing Jul-14 Ongoing

Monitor adherance to continence program through biannual audit reports Dec-14 Advanced Practice Leader (APL) Nursing TBD Pending

IndicatorDomainTimeframe

Current Period (Q1 2014)

Percentage of patients who had a newly occurring pressure ulcer at stages 2 to 4. Numerator - Patients who had a pressure ulcer at stages 2 to 4 on their target assessment and no pressure ulcer at stages 2 to 4 on their prior assessment. Denominator - Patients with valid assessments, excluding those with Stage 2-4 ulcers on prior assessment.

New stage 2 to 4 Pressure UlcerSafetyQ1 2014 (Apr-June 2014)

Performance Management Summary

Reporting Timeline:

0.4% 1.7% Indicator meets or exceeds performance target

Runnymede Unadjusted

Previous Period

(Q4 2013)

Runnymede's performance is better than benchmark and the QIP target. There was 1 New Stage 2-4 Ulcer in Q1 2014 related to declining health condition. Based on root cause analysis, this patient was identified as at risk for wound development. This patient was followed by the wound specialist and the appropriate assessments, protocols and treatments were in place to prevent wound development.

ActionsDue Date

Insert Chart/Graph

Lead

Percentage

Date Initiated

Analysis

0.4%

TBD

Monitor adherance of Braden Pressure Ulcer Risk Assessment through quarterly wound audits Dec-14

CIHINursingHealth Quality Ontario, MAC Quality Committee

Data Source:Clinical Lead:

Reporting Body:

Current Status

Clinical Educators TBD Pending

Indicator Status

Quarterly

PendingRe-launch the Skin and Wound Care Committee Dec-14 Advanced Practice Leader (APL) Nursing

Advanced Practice Leader (APL) Nursing Sep-14 In progress

Coach Charge Nurses to facilitate daily discussions with nursing staff on pressure ulcer prevention in fostering a proactive wound care environment Dec-14

Runnymede - Adjusted

Runnymede - Unadjusted

0%

1%

2%

3%

4%

5%

Fiscal Year

Has a New Stage 2 to 4 Pressure Ulcer

Benchmark

2012 2013 2014

- 6 -

Definition:

Significance:


Apr-14 In Progress

4.3% Opportunities for improvement

Clinical Lead:CIHI

Review and update the Fall Prevention Program policy and procedure Nov-14 Clinical Practice Lead Allied Health Jul-14 In Progress

Quarterly

Indicator StatusRunnymede Unadjusted

Reporting Accountability


Previous Period

(Q4 2013)

Reporting Body:

Lead

Timeframe

Health Quality Ontario, MAC, Quality Committee

PPL -PTData Source:

Indicator

Runnymede's performance continues to better than the benchmark, although showing an increase in percentage in Q1 2014. There were 6 falls captured this quarter compared to 2 in the previous quarter. This is attributed to fall incidents happening within the 30 day MDS assessment period. Falls Audit reports from the Incident Reporting System (IRS) indicate actual falls in Q1 2014 were 27, down from 38 in Q4 2013.

Percent of patients who fell in the last 30 days of their MDS assessment period. Numerator - Patients who had a fall in the last 30 days recorded on their target assessment. Denominator - Patients with valid assessments

The goal of rehabilitation is to encourage the fulfillment of personal goals. Achieving mobility goals includes increased risk of falls. Mitigation of injury from falls is a priority.

5.6% 1.3%

Has FallenSafety

Reporting Timeline:

Q1 2014 (Apr-June 2014)Performance Management Summary

Strategic Focus Area

Due Date

Apr-15

Implement Fall Prevention Program changes recommended by the Fall Prevention Program Committee Apr-15

Manager Pharmacy and Allied Health

Jul-11Physiotherapist

Actions

Percentage

Analysis

Continue with consistent monitoring of adherence to Fall Prevention Program In Progress

Date Initiated Current Status

Insert Chart/Graph

Marginal Benchmark

0%

2%

4%

6%

8%

10%

12%

14%

2012 2013 2014Fiscal Year

Has Fallen



- 7 -

Definition:


Develop methodology to produce monthly compliance reports on outstanding performance evaluations Mar-15 Patient Care Managers TBD Pending

Performance Management Summary

Create audio-visual deliverable targeting catheterization technique or reference tool for nurses Feb-15 Clinical Educators TBD

Educational sessions targeting comprehensive approach to prevent catheter associated UTI Feb-15 Clinical Educators TBD Pending

Data Source:Clinical Lead:

Reporting Body:

Pending

Incorporate annual competency list as items on annual performance evaluation forms



Previous Period

(Q4 2013)

Runnymede Unadjusted Indicator Status

Q1 2014 (Apr-June 2014)Other Clinical IssuesHas UTI

Insert Chart/Graph

Reporting Accountability

Percent of residents with a urinary tract infection during the 30 day observation period. Numerator - Residents with urinary tract infection on their target assessment. Denominator - Residents with valid assessments, excluding end-of-life residents

CIHI

MAC, Quality Committee, Health Quality Ontario

Nursing

Analysis

0.7% 1.0% 2.9% Indicator meets or exceeds performance targetPercentage

PendingTBDClinical Educators

In ProgressAdvanced Practice

Leader (APL) Infection Control

Jul-14

Feb-15

Review best practices and develop deliverables to target specimen collection, preservation and transportation methodology Dec-14

Runnymede's performance remains better than benchmark and the QIP target. RHC continues to decline in UTI rates, which may be attributed to the following: Implementation of the Bowel and Bladder Continence Program, ongoing review and removal of catheters when found no longer medically necessary, and staff education on UTI prevention strategies. All patients who triggered this indicator did not have catheters, but do have long documented history of UTIs (due to incontinence of bowel and bladder, kidney disease, Diabetes, and/or Dementia). Those patients with UTIs were appropriately assessed, monitored and treated for UTI.

ActionsDue Date Date Initiated

Educate reinforcing the Delirium Dementia and Depression policy and that delirium could be symptomatic of UTI.

Lead Current Status

Reporting Timeline:

Clinical Educators

Aug-14

Mar-13 Complete

Quarterly

Marginal

Benchmark

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

2012 2013 2014Fiscal Year

Has UTI

Runnymede -Adjusted

Runnymede -Unadjusted

- 8 -

Definition:


Patient Care Manager

In progressApr-14Clinical Educators

Clinical Lead:

Reporting Body:Reporting Timeline:

Insert Chart/Graph

Quarterly

In progressMay-14

Aug-14Design & complete audit to monitor adherence to Pain Assessment documentation.

Reassess the pain management of patients who are exhibiting signs or symptoms of pain. Aug-14

Runnymede's performance continues to be better than benchmark and the QIP target. Patients identified as having pain during this quarter had uncontrolled pain due to their underlying medical diagnosis, or whose health condition deteriorated. Multiple pain management strategies were utilized to control the pain but proved to be ineffective.

ActionsDue Date Lead Date Initiated Current Status

Percentage

Analysis


CIHI

Health Quality Ontario, Quality Committee, MAC

NursingData Source:


Has PainOther Clinical IssuesQ1 2014 (Apr-June 2014)


Percent of patients with pain. Numerator - Patients with moderate pain at least daily or horrible/excruciating pain at any frequency documented on their target assessment. Denominator - Patients with valid assessments

Improve accuracy of coding of percent of patients with pain on MDS Mar-15 Clinical Educators Nov-14 In progress



Previous Period

(Q4 2013)

Marginal

Benchmark



0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

2012 2013 2014

Fiscal Year

Has Pain

- 9 -

Definition:



Has Worsened PainOther Clinical IssuesQ1 2014 (Apr-Jun 2014)


Reporting Timeline:

Insert Chart/Graph

Percent of residents whose pain worsened. Numerator - Residents with greater pain (higher PainScale score) on their target assessment compared with their prior assessment. Denominator - Residents with valid assessments whose pain symptoms could increase (did not have maximum Pain Scale score on prior assessment) Quarterly



Previous Period

(Q4 2013)

Actions

CIHI

CIHINursing

Data Source:Clinical Lead:Reporting Body:

Improve accuracy of coding of percent of patients with worsening pain on MDS assessments Mar-15

Complete gap analysis for pain management policies, procerdures, education and practices

Percentage

Analysis

4.9% 3.6% 4.3% Opportunities for improvement

Runnymede's performance remains better than benchmark. Through indepth investigation, all patients with worsened pain had multiple pain management strategies utilized to manage the pain. However, due to the patients underlying medical diagnosis or whose health condition deteriorated, the pain worsened. Continue to monitor.

In ProgressClinical Educators

Due Date Lead Date Initiated Current Status

Clinical Educators

Nov-14

Aug-14 CompleteFeb-14

Design and complete audit to monitor adherence to Pain Assessment documentation Jan-15 Clinical Educators Jan-14 In Progress

Marginal

Benchmark



0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

2012 2013 2014

Fiscal Year

Has Worsened Pain

- 10 -

Definition:

Significance:

Target: 100%

Benchmark:

Manual

InternalManager, Pharmacy

Data Source:


Insert Chart/Graph

Quarterly

Theoretical best achieved. No action required.

Action PlanDue Date Lead Current StatusDate Initiated

Analysis

% of Medication Reconciliations on

Admission 100% 100% 100% Indicator meets or exceeds performance goal


Previous Period

(Q1 2014/15)Target Indicator Status

Medications prescribed at admission are reconciled with medications patients may have been taking before admission to RHC, both at prior facility and before that, at home.

Medication Reconciliation at Admission, a comprehensive review of patients' medication regimens at the point of admission, ensures patients safely transition into our facility.Medications prescribed at the prior facility are verified, then patients, their families and or their community pharmacists are consulted, to determine any additional medication patients may have been taking at home.

Medication Reconciliation at AdmissionOperational ExcellenceQ2 2014/15



Runnymede

Target

50%

60%

70%

80%

90%

100%

Q12012

Q2 Q3 Q4 Q12013

Q2 Q3 Q4 Q12014

Q2

Fiscal Year

Medication Reconciliation at Admission

- 11 -

Definition:

Significance:

Target:

Benchmark:

Develop and implement iImprovement stratgey and action plan based on 2014/2015 satisfaction survey results. Mar-15

In progressDec-14Conduct annual Patient Satisfaction Survey

In progressAug-14Chief Planning and Communications Officer

Mar-15

Mar-15

Chief Planning and Communications Officer In progress

Chief Planning and Communications Officer

In progress

In progressApr-14

Sep-14

Continuously engage with staff to raise awareness of the importance of improving the patient experience. Mar-15

Chief Planning and Communications Officer Apr-14

Present survey results to Executive Team, Operations Committee, Patient Family Council, Quality Committee and Board of Directors. Nov-14

Engage with patients and families through different channels to obtain feedback on patient experience and opportunities for improvement.


Performance did not meet target but is not significantly below the Ontario Hospital Association Average Score benchmark. New survey process by NRCC. Only patients with a Cognitivie Performance Score (CPS) of 0-3 were interviewed. 43% of patients interviewed had a CPS score of 3. CPS is used to evaluate cognitive status of patients.


Insert Chart/Graph

Analysis

Patient Satisfaction - Quality of Care

Rating80.4% 83.3% 81.7% Opportunities for improvement

Patient Satisfaction - Quality of Care RatingOperational ExcellenceFY 2014/15



National Research Corporation Canada, Annual Patient Satisfaction Chief Planning and Communications Officer

82.8%. Source: National Research Corporation Canada

Current Period (FY 2014/15)

Previous Period

(FY 2013/14)Target Indicator Status

National Research Corporation Canada (NRCC): Patient Satisfaction - "Overall quality of care/services rating"

81.7%

The Ontario Hospital Association worked closely with NRCC to establish questions that would most appropriately measure patient satisfaction. The overall quality of care rating is based on several domains which have been corelated with quality of care. These domains are: Long Stay Resident Experience medical care & treatment, autonomy, dignity, staff, food, living environment and activities.

Internal

Data Source:

Indicator Owner:

Reporting Body:Reporting Timeline: Annual

Out of Target

Target

Benchmark Runnymede

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

2012/2013 2013/2014 2014/2015Fiscal Year

Patient Satisfaction - Quality of Care Rating

- 12 -

Definition:

Significance:

Target:

Benchmark:

Family/Visitor Satisfaction - Quality of Care RatingOperational ExcellenceFY 2014/15



National Research Corporation Canada (NRCC): Family/Visitor Satisfaction - "Overall quality of care/services rating"

The Ontario Hospital Association worked closely with NRCC to establish questions that would most appropriately measure family/visitor satisfaction. The overall quality of care rating is based on several domains which have been corelated with quality of care. These domains are: global quality, care and services, activities, communication, living environment and assistance with living.

93.1%

Current Period (FY 2014/15)

Annual

National Research Corporation Canada, Annual Patient Satisfaction Chief Planning and Communications OfficerInternal

Data Source:

Indicator Owner:

Reporting Body:

93.1% Opportunities for improvement

91.9%. Source: National Research Corporation Canada Previous

Period(FY 2013/14)


Present survey results to Executive Team, Operations Committee, Patient Family Council, Quality Committee and Board of Directors. Nov-14

Engage with patients and families through different channels to obtain feedback on patient experience and opportunities for improvement.

Reporting Timeline:

Performance did not meet target but is not significantly below the Ontario Hospital Association Average Score benchmark. Further information is required to identify potential resons for decline in satisfaction.


Insert Chart/Graph

Family Satisfaction - Quality of Care Rating

Analysis

87.0% 96.2%

In progressDec-14Conduct annual Patient Satisfaction Survey Mar-15

Chief Planning and Communications Officer In progress


Mar-15 Chief Planning and Communications Officer Apr-14

Sep-14Develop and implement iImprovement stratgey and action plan based on 2014/2015 satisfaction survey results. Mar-15

Continuously engage with staff to raise awareness of the importance of improving the patient experience. Mar-15

Chief Planning and Communications Officer Apr-14 In progress

In progress

In progressAug-14Chief Planning and Communications Officer

Out of Target

Target

Benchmark Runnymede Performance

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

2012/2013 2013/2014 2014/2015Fiscal Year

Family/Visitor Satisfaction - Quality of Care Rating

- 13 -

Definition: Patient Relations Records

Significance:

Target:

Benchmark:


Percentage of reported patient and or family member concerns that have not been resolved.

Percentage of Unresolved Patient ComplaintsOperational ExcellenceQ2 2014/15



Internal

Data Source:Indicator Owner:


Runnymede is committed to patient centred care and continuous quality improvement. This indicator ensures pateint concerns are monitored and addressed.


Previous Period


Target has been met. No further action required.


Insert Chart/Graph

Percentage of Unresolved Patient

Analysis

0% 0% 0% Indicator meets or exceeds performance target

0%

N/A

Quarterly

Target

Marginal

Out of Target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2013/2014 2014/2015Fiscal Year

Percentage of Unresolved Patient Complaints

- 14 -

Definition:VP Clinical Programs

Significance:

Target:

Benchmark:

There were no critical incidents in Q2.

Action PlanDue Date Lead

Analysis

0 0 0 Indicator meets or exceeds performance target

Reporting Timeline:

Insert Chart/Graph

Implementation of approved QCIPA review recommendations. Mar-15 In ProgressJun-14VP Clinical Programs


Quarterly

Number of Critical Patient Incidents

Measures the safety of our patient care services. Any result greater than zero represents significant harm experienced by a patient or patients and significant risk of liability for the hospital.


Previous Period


0

N/A

Number of Critical Patient Incidents per quarter, where a critical incident is any unintended event that occurs when a patient receives treatment in the hospital, that results in death or serious disability, injury or harm to the patient, and does not result primarily from the patient's underlying medical condition from a known risk inherent in providing treatment.

Number of Critical Patient IncidentsOperational ExcellenceQ2 2014/15



Internal

Data Source:Indicator Owner:Reporting Body:

Incident Reporting System

Target

Marginal

Out of Target

0

1

2

3

4

5

2013/2014 2014/2015Fiscal Year

Number of Critical Patient Incidents

- 15 -

Definition:

Significance:

Target:

Benchmark:

Lost Time Due to InjuryOperational ExcellenceQ2 2014/15



Annual target = 1.66

Lost Time Due to Injury is the average number of allowed Workplace and Safery Insurance Board (WSIB) lost time injury claims per 195,000 employee hours worked. The Lost Time Due to Injury indicator can be used to determine the effectiveness of the organization's efforts on accident and injury prevention compared to other hospitals within the same rate group.

A high or increasing Lost Time Due to Injury Rate may indicate an improvement is needed in workplace safety-related initiatives and/or increased education on safe work processes.

The benchmark rate of 1.66 is the Lost Time Injuries (LTI) rate established by the WSIB for Hospitals (Group 853). The LTI rate is determined as the number of LTIs per 100 FTEs (195,000 hours worked).


Previous Period


Reporting Timeline:

Insert Chart/Graph

Annual



LTI Rate

Analysis

0.42 0.98 1.66 Indicator meets or exceeds performance target

Occupational Health

Workplace Safety & Insurance BoardChief Planning and Communications Officer


Director, Human Resources Jul-14 Ongoing

Develop new policy and standard operating procedures to facilitate early and safe return to work program for employees experiencing work related injuries to avoid lost claims - occupational health will work with human resources, employee, manager, union representative.

Nov-14

Target

Marginal

OutofTarget

Ben

chm

ark

Ben

chm

ark

Run

nym

ede

Run

nym

ede

0

0.5

1

1.5

2

2.5

3

2013/2014 2014/2015

LTI R

ate

Fiscal Year

Lost Time Due To Injuries

- 16 -

Definition:

Significance:

Target:

Benchmark:

Annual target = 9.20%

Turnover RateOperational ExcellenceQ2 2014/15



The turnover rate is defined as the number of permanent employees that left the employment of Runnymede Healthcare Centre (i.e. voluntary or involuntary). As a means of ensuring statistical significance for the data a fiscal year time period will be used to measure the turnover rate.

Current Status


Turnover Rate

Due Date Lead Date Initiated


Previous Period

(Q1 2014/15)3.83% 3.93% 9.2% Indicator meets or exceeds performance target

Analysis

A high turnover rate may indicate employee dissatisfaction and the need to determine the root causes for the high turnover rate and implementing or changing initiatives and strategies to retain staff.

The benchmark will be the 25% percentile turnover rate for Hospitals as set out in the Saratoga Human Resources Benchmarking Survey conducted by the Ontario Hospital Association and Price Waterhouse.


Action Plan

Human Resources

OHA, Price WaterhouseHuman Resources

Annual

Data Source:Indicator Owner:Reporting Body:Reporting Timeline:

Insert Chart/Graph

Target

Marginal

Out of Target

Ben

chm

ark

Ben

chm

ark

Run

nym

ede

Run

nym

ede

0

2

4

6

8

10

12

14

16

18

20

2013/2014 2014/2015

Turn

over

Rat

e (%

)

Fiscal Year

Turnover Rate

- 17 -

Definition:

Significance:

Target:

Benchmark:

In Progress



Action Plan

Internal

Continue to support educational opportunities for all employees. Mar 31 2015 OngoingChief Operating Officer

Chief Operating Officer


Insert Chart/Graph

Analysis

Quarterly

1.24% 1.19% 1.75% Opportunities for improvement

Indicator Status

Ensure staff orientation and education is captured correctly in the Payroll System. Mar 31 2015 Chief Operating Officer Nov-14 In Progress

Due Date Lead

Total Education Expenses as a percentage of Total Operating Expenses. Education expenses defined as all costs related to the education functional cost-centre, orientation expenses, education days and course registration.

1.75% of Operating Expenditures

1.75%

Indicator performance is below benchmark and target.

Current Period

(Q2 2014/15)

Previous Period

(Q1 2014/15)Target

Learning and education is proven to position Runnymede to Lead the Way in Specialized Complex Continuing Care, through ensuring staff are up to date and have the knowledge to provide the best care for adults with neurological disorders, chronic illnesses, and palliative needs. Education shows the organization's commitment to quality and excellence, with a recognized culture of efficiency, effectiveness, a committment to best practice, and continuous improvement.

Percentage of Budget Allocated to

Staff Education

Financial and Payroll Records

Percentage of Budget Allocated to Staff EducationOperational ExcellenceQ2 2014/15



Out of Target

Marginal

Target

Runnymede Performance

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

2011/2012 2012/2013 2013/2014 2014/2015

Fiscal Year

Percentage of Budget Allocated to Staff Education

- 18 -

Definition:

Significance:

Target:

Benchmark:

Workplan Status Report

Percentage of IT Projects Completed on BudgetOperational ExcellenceQ2 2014/15



Data Source:The number of approved applications and information technology (IT) projects completed within the annual capital budget approved.

100%

N/A

Insert Chart/Graph

Indicator meets performance target. No action required.

Current Period

(Q2 2014/15)

Previous Period

(Q1 2014/15)Target

Project management methodologies and procurement guidelines are applied to ensure expenditures meet financial targets and ensure cost containment.

Percentage of Internal IT Project

Completed on Budget

Quarterly

Indicator Status

COOIndicator Owner:Reporting Body: InternalReporting Timeline:

Analysis

Action PlanDate Initiated Current StatusDue Date Lead


Out of Target

Marginal

Target Runnymede Performance

0%

20%

40%

60%

80%

100%

Fiscal Year

Percentage of Internal IT Projects Completed on Budget

- 19 -

Definition:

Significance:

Target:

Benchmark:

EMRAM ScoreGrowthQ2 2014/15



Healthcare Information Management Systems Society (HIMSS) Analytics Electronic Medical Record (EMR) Adoption Model (EMRAM) score. Score is calculated by the Ontario Hospital Association/HIMSS based on the results of the OHA eHealth Technologies & Applications Data Entry Interface.

The score identifies the levels of electronic medical record (EMR) capabilities ranging from limited ancillary department systems through a paperless EMR environment. The score enables the hospital to compare with peer organizations in Canada and the U.S. The information supports the hospital's strategy to complete the EMR and participation in the electronic health record (EHR).

1.00

1.13 Average EMRAM score for peer group (CCC, Rehab & Mental Health) Source: eHealth Technologies

COOIndicator Owner:

eHealth Technologies and Applications Status Report

Due Date

Jan-15

Current Period

(Q2 2014/15)

Previous Period


EMRAM Score

Analysis

0.005 0.005 1.000 Opportunities for Improvement

Dec-14

Jul-14COO/Vice President Clinical Programs

Nov-14

Ontario Hospital Association/HIMSS

Director of Information Services & Facilities

ManagementAug-14

Lead Date Initiated Current Status

In progress

There is strong partnership support between the two organization's President and Chief Executive Officer for the project. Meetings between organizations at an executive level continue.

Second a Project Manager (SJHC to hire an incumbent into the position). Jan-15

Action Plan

Create an EPR scorecard.

Data Source:


Insert Chart/Graph

Director of Information Services & Facilities

Management

Quarterly

In progressNov-14Director of Information Services & Facilities

Management

In progress

In progressFinalize MOU and Project Charter.

Engage an Implementation Consultant to deliver an Electronic Patient Record framework including a Business Case and Key Milestone Schedule Dec-14

Out of Target

Marginal

Target


0

0.2

0.4

0.6

0.8

1

Fiscal Year

EMRAM Score

- 20 -

Definition:

Significance:

Target:

Benchmark:

Patient days (the number of patients per day) are grouped into Resource Utilization Groups (RUG) which are assigned a weight to create a RUG Weighted Patient Day (RWPD). RWPDs are calculated as the number of days associated with a RUG III group multiplied by the group specific case mix index (CMI) value [RWPD = CMI x Patient Days].

RUGs Weighted Patient DaysGrowthQ2 2014/15



Indicator Owner:Reporting Body:

CIHIVP Clinical Programs

Data Source:


Insert Chart/Graph

Reporting Timeline:

The RWPD is a reflection of both patient acuity and volumes. A higher RWPD value indicates higher patient acuity and/or higher patient volumes. Runnymede's ability to provide increased RWPD demonstrates the hospital's participation as a system partner in caring for medically complex patients and ensuring that patients requiring complex continuing care have access to the services they require.

RUGs Weighted Patient Days

Analysis

20,800 20,863 87,047 Opportunities for improvement


Previous Period


Annual: 87,047 RWPD. Source H-SAA. (Quarterly target: 21,762 RWPD)

N/A

Implement recommendations from CMI analysis report & review ipact to CMI

Target 100% occupancy with appropriate patient population.

Mar-15

Mar-15

MOHLTC, TC LHINQuarterly

In ProgressAug-14MDS Coordinators

OngoingVP Clinical Programs Jan-14

Q2 results are preliminary estimate as data not yet available from CIHI. RWPD is below target due to an average occupancy of 97% and an estimated facility-wide CMI of 1.17. The target is based upon achieving 100% occupancy and 95 beds at a CMI of 1.12 and 105 beds at a CMI of 1.3.

Action PlanDue Date

Actu

al A

ctua

l Act

ual A

ctua

l

Actu

al A

ctua

l

Fore

cast

Fore

cast

Fore

cast

Fore

cast

Fore

cast

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

Q1 Q2 Q3 Q4 Q1 Q2

2013/2014 2014/2015

RUGs Weighted Patient Days

- 21 -

Definition:

Significance:

Target:

Benchmark:

Adopt Incident Reporting System to capture all transfers to Emergency Department. 01-Apr-14 Vice President of Clinical Programs 01-Apr-14 Complete

Enhancing knowledge and skills regarding clinical procedures through implemention of online reference resource/database for clinical staff. 16-Nov-14 Chief Nursing Executive 01-May-14 In Progress

Review best practices and develop oral care policy in collaboration with Runnymede Dental Centre. Develop and disseminate education. 01-Jan-15 Chief Nursing Executive 01-Sep-14 In Progress

Eliminate use of lemon glycerin swabs on Patient Care Units.


Insert Chart/Graph

Quarterly

Complete 01-Sep-14Chief Nursing Executive

Chief Nursing Executive

Chief Nursing Executive 01-Sep-14 In Progress

16-Sep-14

15-Feb-15

Education sessions for employees involved in patient care regarding effective interpersonal and asssessment skills ( Including SBAR). 16-Mar-15

Education pertaining to importance of reflective practice and quality assurance. Incorporate Nursing Interventions Classification (NIC) and North American Nursing Diagnosis Association International (NANDA-I) in existing educational deliverables.

The performance of this indicator is below the target. Annual review of target will be conducted in Mar 2015.


In Progress 01-Sep-14

Reducing the number of patients transferred to acute care improves the patient experience by reducing the number of transitions for a patient and reduces the overall burden on the health care system. Where possible, RHC should seek to expand clinicians' scope of practice to reduce the need for transfer to acute care. A higher number of transfers to the emergency department may signify a higher patient acuity level.

Number of Annual ED Transfers

Analysis

2.47 2.17 1.94 Opportunities for improvement

1.94 Admissions per 1000 Patient Days

N/A



The cummulative number of patients transferred to the emergency department of an acute care hospital during the fiscal year per 1000 patient days. The patient may have or may not have been admitted to acute care.

Annual ED TransfersGrowthQ2 2014/15



Data Source:Indicator Owner: Chief Nursing Executive

Health Information Services

Internal

Target

Marginal

Out of Target

Q1 Q

1

Q1

Q2

Q2

Q2

Q3

Q3

Q4

Q4

0

1

2

3

4

5

6

7

8

9

10

2012/13 2013/14 2014/15Fiscal Year

Number of Annual ED Transfers

- 22 -

Definition:

Significance:

Target:

Benchmark:

Data Source:


Insert Chart/Graph

Financial Statements

MOHLTCIndicator Owner: Chief Operating Officer

Quarterly

Performance is on track to meet target and benchmark. No action is required.


Percentage of Non-MOHLTC Revenue

Analysis


Total revenue earned from other sources (all revenue not derived from MOHLTC) divided by Total Revenue (all sources).

15.0%

MOHLTC revenue is limited. Revenue has not kept pace with inflation and other operating expense pressures. Hospitals must seek out alternative ways to maximize revenue.

14.4% Source: HIT Tool (YE data 2013/14 YE Chronic/Rehab hospitals)

Current Period

(Q2 2014/15)


Percentage of Non-MOHLTC Revenue GrowthQ2 2014/15



Out of Target

Marginal

Target

Benchmark

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

2012/13 2013/14 2014/15Fiscal Year

Percentage of Non-MOHLTC Revenue

Runnymede

- 23 -

Definition:

Reporting Body: MOHLTC

Significance:

Target:

Benchmark:

- financial budget reports issued monthly by the 24th of the following month - vacation reports issued 7 days after the pay deposit date - a new statistical report to be determined based upon management input

CompletedJul-14Aug-14Feb-15 In Progress

HIT Tool (MOHLTC)Chief Operating Officer

Operationalize the Case Costing Data for improvements and efficiencies.

Data Source:

Quarterly

Chief Operating Officer

Indicator Owner:

Reporting Timeline:

Insert Chart/Graph

In Progress Apr-14Chief Operating Officer

Support reinvestment in Quality Improvement Measures to deliver better care more effectively.

Implementation of electronic management reports that meet the needs of the department heads for decision making purposes.

In Progress Apr-14

In Progress Jun-14Deputy CFO

Mar-15

Mar-15

Jun-14

Jun-14 CompletedDeputy CFODeputy CFODeputy CFO

Jul-14

Maintain a balanced budget, approved in advance of the beginning of the fiscal year. Mar-15

Total Margin for Q2 2014/2015 exceeds the benchmark and the target.


Total Margin

Analysis

6.68% 4.49% 0% Indicator meets or exceeds performance target



Percent by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expenses, excluding the impact of facility amortization in a given year.

0%

Financial effectiveness and viability reflects the hospital's ability to operate within funding/revenues earned. This indicates that there is operational efficiency, ensuring that there are sufficient resources required to purchase necessary equipment and provide patient care.

4.5% Source: HIT Tool (2013/14 YE Chronic/Rehab hospitals)

Total MarginGrowthQ2 2014/15



Out of Target

Target

Runnymede

-5%

0%

5%

10%

15%

FY 2012/2013 FY 2013/2014 FY 2014/2015

Fiscal Year

Total Margin

Marginal

Benchmark

- 24 -

Definition:

Significance:

Target:

Benchmark:

Current RatioGrowthFY 2014/15



Current Period

(Q2 2014/15)

Previous Period(Q1 2014/15) Target Indicator Status

Current Assets ÷ Current Liabilities, The number of times a hospital's short term obligations can be paid using the hospital's short term assets.

The hospital's ability to pay current liabilities including staff salaries and wages which comprise of approximately 75% of expenses allows management to focus on operational excellence/quality care for our patients and community.

1.00

1.00 Source: Hit Tool (2013/2014 YE Chronic/Rehab hospitals)

Current Ratio

Analysis

1.65 1.48 1.00 Indicator meets or exceeds performance target

Performance for Q2 2014/15 is positive and exceeds target and benchmark.


HIT Tool (MOHLTC)

MOHLTCChief Operating Officer

Data Source:Indicator Owner:Reporting Body:Reporting Timeline:

Insert Chart/Graph

Quarterly

Out of Target

Marginal

Target

Benchmark

0.5

1

1.5

2

FY 2012 FY 2013 FY 2014

Fiscal Year

Current Ratio

Runnymede

- 25 -

Definition:

Significance:

Target:

Benchmark:

Number of New PartnershipsGrowthQ2 2014/15




Opportunities for Improvement

Action Plan

Performance on track to meet target. Future partnerships are in discussion and have not been formalized.Analysis

1 3Number of New Partnerships 1

Continue to pursue partnership opportunities. Mar-15 In progressApr-14Senior Executive Team



Insert Chart/Graph

Quarterly

Manual Count

Internal


Number of new Partnerships between Runnymede Healthcare Centre and other organizations.

Annual Target = 3

N/A

Current Period (Q2 2014/15) Target Indicator Status

Runnymede Healthcare Centre will pursue strategic partnerships, where appropriate, to facilitate growth and improve operational efficiency.

Previous Period

(Q1 2014/15)

Out of Target

Marginal

Target

Q1

Q1

& Q

2

Q4

Q4

0

1

2

3

4

5

6

2012/2013 2013/2014 2014/2015Fiscal Year

Number of New Partnerships

- 26 -

Definition: Manual count

Significance:

Target:

Benchmark:

The number of patients admitted to Runnymede's 3 West Low Tolerance Long Duration Rehabilitation (LTLD Rehab) Program from St. Joseph's Health Centre (SJHC). This includes inpatients as well as patients referred from SJHC Ambulatory clinics (outpatients).

Number of LTLD Rehab Patients Admitted from SJHCGrowthQ2 2014/15




SJHC, InternalReporting Body:Reporting Timeline:

VP, Clinical Programs


Previous Period


Annual forcast is projected at 226 patients annually. There continues to be a high occupancy on the unit and as the ALOS decreases, the number of patients admitted increases.

Insert Chart/Graph

SJHC has the highest percentage of Alternate Level of Care (ALC) patients in the Toronto Central LHIN. This collaboration will help to alleviate system pressures by freeing up acute care beds at SJHC and transitioning patients to a more appropriate setting at Runnymede. The LTLD Program will ensure patients that require a slower pace less intensive rehab will receive the right care at the right place. On May 14, 2012, 34 new LTLD Rehab beds were opened in collaboration with SJHC which resulted in the hiring of over 60 new professionals.

Number of LTLD Patients Admitted

from SJHC57 56 45 Indicator meets or exceeds performance target

01-Apr-14VP Clinical Programs

Analysis

180 patients annually (45 patients quarterly)

n/a

Quarterly

In Progress


Implement 2014/15 ALC Avoidance Strategy. 1-Mar-15

Out of Target

Marginal

Target

Act

ual A

ctua

l

Act

ual A

ctua

l

Act

ual

Act

ual

Act

ual

Act

ual

Act

ual

For

ecas

t

Fore

cast

For

ecas

t

Fore

cast

Fore

cast

For

ecas

t

Act

ual

Fore

cast

For

ecas

t

0

50

100

150

200

250

2012/2013 2013/2014 2014/15Fiscal Year

Number LTLD Patients Admitted from SJHC

- 27 -

Definition:

Significance:

Target:

Benchmark:3 - 6 months. Source: GTA Rehab Network

Manual Count

SJHC, InternalVP Clinical Programs

Quarterly

Data Source:

Lead Date Initiated

The ALOS continues to trend downwards. The shorter length of stay facilitates the admission of a greater volume of patients.

Action PlanDue Date

Insert Chart/GraphAnnual average = 69 days

A higher average length of stay will result in a lower patient turnover rate and hence will decrease the number of patients who can access the LTLD Rehab Program. An average length of stay less than 69 days would warrant a review of the complexity of patients accessing the program.

Patients admitted to Runnymede's Low Tolerance Long Duration Rehabilitation (LTLD Rehab) Program from St. Joseph's Health Centre (SJHC) effective May 14, 2012. This includes inpatients as well as patients referred from SJHC Ambulatory clinics (outpatients). 1 patient requiring LTLD Rehab was admitted to Runnymede from SJHC during the period of April 1 - May 13, 2012. This patient was not included in the data for purposes of monitoring metrics outlined in the agreement between Runnymede and SJHC. Average Length of Stay ( ALOS) SJHC LTLD Rehab Patients = Sum of the Length of stay of separated patients (days)/Number of patients separated year to date. Separations = patients who are discharged from Runnymede to an alternate level of care (e.g. home, acute care, LTC, etc.) and patients who have deceased.



Current Status

Previous Period


ALOS LTLD Rehab Patients

Analysis

50.4 55.5 days 69 days Indicator meets or exceeds performance target

Average Length of Stay of SJHC LTLD Rehab PatientsGrowthQ2 2014/15



Implementation of 2014/15 ALC avoidance strategy. Mar-15 VP Clinical Programs Apr-14 In Progress

RHC

Out of Target

Marginal

Target

Benchmark

0

10

20

30

40

50

60

70

80

90

100

2011/2012 2013/2014 2014/2015

Day

s

Fiscal Year

Average Length of Stay of LTLD Rehab Patients (Quarterly)

Runnymede

- 28 -

Definition:

Significance:

Target:

Benchmark:

Number of External Committee AppointmentsRelationshipsQ2 2014/15




Opportunities for Improvement

Action Plan

Target has been met. No furter action required.Analysis

1 2Number of External Committee Appointments 4



Insert Chart/Graph

Quarterly

Manual Count

Internal


Number of staff that have joined Provincial, TC LHIN or Health Sector committees/ task forces/working groups since April 1, 2014.

Annual Target = 2

N/A

Current Period (Q2 2014/15) Target Indicator Status

Promote Runnymede as a CCC sector leader through representation on Provincial, TC LHIN and Health Sector committee/ task forces/working groups. Ties in with Runnymede's vision of leading the way in complex continuing care.

Previous Period

(Q1 2014/15)

Out of Target

Marginal

Target

Q1

Q2

Q2

Q3

Q4

0

1

2

3

4

5

6

7

8

9

10

2013/2014 2014/2015Fiscal Year

Number of New External Committee Appointments

- 29 -

Definition:

Significance:

Target:

Benchmark:

Number of Board Committee AppointmentsRelationshipsQ2 2014/15


IndicatorStrategic Focus Area


Indicator meets or exceeds performance target

Action Plan

5

Target has been met. No further action required.Analysis

5 5Number of Board Committee Appointments

Number of external Board of Directors appointments of Runnymede executives.

Annual Target = 5

N/A


Timeframe


Board appoinments support continuous leadership development and provides increased recognition for both the individual and Runnymede Healthcare Centre.

Previous Period

(Q1 2014/15)


Reporting Body:Reporting Timeline: Quarterly

Manual CountChief Planning and Communications Officer

Insert Chart/Graph

Marginal

Target

Q1

& Q

2

0

1

2

3

4

5

6

7

8

2014/2015Fiscal Year

Number of Board Committee Appointments

- 30 -

Definition:

Reporting Body: Internal

Significance:

Target:

Benchmark:

Student Satisfaction SurveyChief Nursing Executive


Reporting Timeline:

Insert Chart/Graph

Quarterly

Share information with partnering institutions regarding learning opportunities in Runnymede's changing patient population.

30-Jan-15 In Progress9-Aug-14Chief Nursing Executive

Satisfaction results exceed the target.


Student Satisfaction

Analysis


Percentage of students who answered "likely" or "very likely" (or at least 4 out of 5 on numerical scale) to the question: "How likely are you to recommend Runnymede to other students?"

75%

Measures student satisfaction for the year with respect to our ability to provide a positive learning experience. Also students are a source for future hires.

n/a



Annual Student Satisfaction ScoresRelationshipsQ2 2014/15



Out of Target

Marginal

Target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q1 Q2 Q3 Q4 Q1 Q2

Perc

enta

ge o

f stu

dent

s w

ho r

espo

nded

favo

urab

ly

Fiscal Year

Student Satisfaction

2013/2014 2014/2015

- 31 -

Definition: Education Records

Significance:

Target:

Benchmark:

Quarterly

In Progress


Needs assessment exercise to identify where graduate students can be placed at Runnymede. 30-Jan-15

Insert Chart/Graph

01-Sep-14Chief Nursing Executive

Providing student placements and experiences builds our relationships with academic centres.

Number of Annual Student Days

Analysis

240 522 1,989 Opportunities for improvement

Annual target = 1989

n/a


Previous Period (Q1 2014/15) Annual Target Indicator Status

Runnymede is expecting more students in fall and winter sessions based on the past two year trend and hence it is expected that performace will meet target.

Chief Nursing ExecutiveNumber of students' days in attendance at Runnymede as part of an academic program.This includes clinical and non clinical students, but does not include volunteers.

Number of Annual Student DaysRelationshipsQ2 2014/15




InternalReporting Body:Reporting Timeline:

Out of Target

Marginal

Target

Q1 Q1 Q1

Q2

Q2

Q2

Q2

Q3

Q3

Q3

Q4

Q4

Q4

0

500

1000

1500

2000

2500

3000

3500

4000

2011/12 2012/13 2013/14 2014/15Fiscal Year

Number of Annual Student Days

- 32 -

Definition:

Significance:

Target:

Benchmark:

RelationshipsQ2 2014/15



Number of Presentations/Publications Annually

N/A


Previous Period



Communications

Internal



Reporting Body:Reporting Timeline: Quarterly

Analysis

Insert Chart/Graph

Continuing professional development is a commitment to ensuring leaders and practitioners are reflective thinkers who pursue excellence through life long learning. In the context of their practice, learning ensures knowledge, skills and competencies. This should be shared with colleagues and peers reflecting the expertise and skill sets at Runnymede enhancing the reputation and recognition to the hospital. An increased number of presentations and publications will assist to promote Runnymede as a leader in complex continuing care and increase the public's awareness regarding its mission, vision and values.


Stemming from reading or research, number of poster presentations or speaking engagements at external conferences or workshops in the healthcare or related field. Would include relevant teaching and speaking. Also number of publications authored by Runnymede staff.

Number of Presentations/ Publications Annually 4 4 4

Indicator meets or exceeds performance target

Annual Target = 4

Out of Target

Target

Q1

Q4

0

1

2

3

4

5

6

7

8

9

10

2013/2014 2014/2015

Cum

ulat

ive

NU

mbe

r of P

rese

ntat

ions

or P

ublic

atio

ns p

er Y

ear

Fiscal Year

Number of Presentations or Publications Annually

Q1

- 33 -

Definition:

Significance:

Target:

Benchmark:

Due Date

Reporting Timeline:


Action Plan

Insert Chart/Graph


Analysis

N/A

22,921 11,142 39,976 Indicator meets or exceeds performance targetNumber of Visits per

Quarter

Performance is on track to meet target. Continue to market the use of Runnymede website. New target determined by taking Q4 total, multiplying it by four and adding 5 percent.

The Runnymede website is used to provide information and resources to external stakeholders and assist them in their decision making related to careers, volunteering, patient care and/or charitable donations. The website enhances Runnymede's profile within the community and with other healthcare organizations and can be used to facilitate an interactive relationship between us and our stakeholders by providing an opportunity for visitors to submit comments/feedback.


Previous Period


Annual Target = 39,976

The units of measurement are "visits", where the Runnymede Healthcare Centre website is accessed and explored.


IndicatorStrategic Focus Area

Measure of Website TrafficRelationships

Timeframe Q2 2014/15

Data Source:

Quarterly

Runnymede Website

Internal

Indicator Owner:

Reporting Body:

Out of Target

Marginal

Target

Q1

Q2

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

2014/2015Fiscal Year

Measure of Website Traffic

- 34 -

Definition:

Significance:

Target:

Benchmark:

Completion of a Document Management RFP.Initiate a series of vendor discovery demonstrations to assist Runnymede team with project scope decision making. 2014/12/01

Quarterly

33% 0% 100% Opportunities for improvement

Indicator Status

100%

Percentage of Corporate

Departmental Processes

Transitioned to Electronic

Director of Information Services & Facilities Management

2014/09/01 In Progress

Reporting Timeline:

Date InitiatedDue Date Current Status

Insert Chart/Graph

Action Plan

Analysis

Current Period

(Q2 2014/15)

Previous Period

(Q1 2014/15)Target

A paperless strategy will reduce solid waste generation and support the hospital's "green" approach. The focus for Phase 1 is to transition corporate departmental processes to electronic. Subsequent phases will focus on patient care processes.

Lead

N/A

Donation Management System completed System Center 2012 module build complete.

Workplan Status ReportCOO

Percentage of Corporate Departmental Processes Transitioned to ElectronicOperational ExcellenceQ2 2014/15



The number of corporate departmental processes transitioned to electronic completed compared to the annual plan. Internal


Communications work order queue 2014/12/01 Director of Communications 2014/08/01 In ProgressPatient Relations Compliments and Concerns - Development of an application build and roll-out schedule. 2014-10-03

Chief Communications and Corporate Planning 2014/07/14 In Progress

Electronic Boardroom - Solution analysis and demonstrations to be completed. Once completed, product acquisition and deployment will occur. 2014-11-01

Director of Information Services & Facilities Management

2014/06/01 In Progress

Out of Target

Marginal

Target


0%

20%

40%

60%

80%

100%

Fiscal Year

Percentage of Corporate Departmental Processes Transitioned to Electronic

2012/13 2013/14 2014/15

Runnymede Balanced Scorecard Overview Q2 2014-2015BSC TemplateV2

4 Alternate Level of Care Rate-Q2 2014-15ALC Rate

05 Has a New stage 2-4 PUSheet1

06 Has FallenSheet1

07 Has UTISheet1

08 Has PainSheet1

09 Has Worsened PainSheet1

10-revised Graph-Medi Rec at AdmissionSheet1

11 Patient Satisfaction re Quality of Care Rating Q2 2014Sheet1

12 Family Satisfaction re Quality of Care Rating Q2 2014Sheet1

13 Percentage of Unresolved Patient Complaints Q2 2014Sheet1

14 Number of Critical Patient Incidents Q2 2014-2015Sheet1

15 Lost Time Due To Injury Q2 2014Sheet1

16 Scorecard Turnover Rate Q2 2014Sheet1

20 RUGs Weighted Patient Days Q2 2014-2015Sheet1

21 ED Transfers Q2 2014-2015Sheet1

25 Partnerships Q2 2014Sheet1

26 LTLD from SJHC Q2 2014-2015Sheet1

27 ALOS LTLD Rehab Q2 2014-2015Sheet1

28 Number of External Committee Appointments Q2 2014Sheet1

29 Number of Board Committee Appointments Q2 2014Sheet1

30 Student Satisfaction Q2 2014-2015Sheet1

32 Presentations or Publications Q2 2014Sheet1

33 Measure of Website Traffic Q2 2014Sheet1

Runnymede Balanced Scorecard Overview Q2 2014-2015.pdfBSC TemplateV2

02 Rate of C Diff Infection Q2 2014-2015.pdfSheet1

03 Hand Hygiene Compliance Q2 2014-2015.pdfSheet1

17 Percentage of Budget Allocated to Staff Education Q2 2014-2015.pdfgraph

18 Percentage IT Completed Q2 2014-2015.pdfSheet1

19 EMRAM Score Q2 2014-2015 -BW.pdfSheet1

22 Percentage of Non MOHLTC Revenue Q2 2014-2015.pdfgraph

23 Total Margin Q2 2014-2015.pdftable

24 Current Ratio Q2 2014-2015.pdftable

31 Student Days Q2 2014-2015.pdfSheet1

34 Percentage Paperless Q2 2014-2015-BW.pdfSheet1

13 Percentage of Unresolved Patient Complaints Q2 2014.pdfSheet1

21 ED Transfers Q2 2014-2015.pdfSheet1

27 ALOS LTLD Rehab Q2 2014-2015.pdfSheet1

28 Number of External Committee Appointments Q2 2014.pdfSheet1

02 Rate of C Diff Infection Q2 2014-2015.pdfSheet1

09 Has Worsened Pain.pdfSheet1

11 Patient Satisfaction re Quality of Care Rating Q2 2014.pdfSheet1

12 Family Satisfaction re Quality of Care Rating Q2 2014.pdfSheet1


22 Percentage of Non MOHLTC Revenue Q2 2014-2015.pdfgraph

24 Current Ratio Q2 2014-2015.pdftable


Runnymede Balanced Scorecard Overview Q2 2014-2015.pdfBSC TemplateV2

03 Hand Hygiene Compliance Q2 2014-2015.pdfSheet1

4 Alternate Level of Care Rate-Q2 2014-15.pdfALC Rate



06 Has Fallen.pdfSheet1

20 RUGs Weighted Patient Days Q2 2014-2015.pdfSheet1

runnymede balanced scorecard€¦ · cdi can spread when individuals come into contact with objects...

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