corporate monitor

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CORPORATE MONITOR

Key Performance IndicatorsJuly - September 2010

Quarter 2

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Table of Contents

Introduction 3

Goal #1 Excellence in Patient Care 4

Goal #2 Active Healthy Work Environment 15

Goal #3 Strong Financial Performance 22

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Introduction

The West Lincoln Memorial Hospital Corporate Monitor provides a quarterly report on Performance. The Indicators have been identified to reflect the Hospital’s three Strategic Goals, which are:

Highlights of Q2• WLMH continues to meet or exceed targets in Patient Satisfaction for all areas monitored, with the Obstetrical Department achieving the highest performer ranking in Ontario for Community Hospitals;• Average length of stay for Emergency Room patients continues to be too long. New initiative, Patient Flow Coordinator, ramping up in January 2011 which should facilitate improvement;• ALC Days remain constant over Q2 and are approaching the target, however WLMH experiencing pressure in this area in Q3;• Absenteeism rates continue to be above the OHA average. Recent initiatives include: memos to staff and physicians to promote awareness and identification /counseling of individual high sick time users.

Strategic Goal #1 Excellence in patient care

Strategic Goal #2 Active, healthy work environment

Strategic Goal #3 Strong financial performance

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Excellence in patient care

Key Performance Indicators:

Patient Overall Satisfaction Rate - Medicine/Surgery

Patient Overall Satisfaction Rate - Obstetrics

Patient Overall Satisfaction Rate - Emergency

Average Length of Stay for ER Patients By Triage Level

ER Patients Left Without Being Seen By Triage Level

Weighted Case Volume

Number Of Patients Admitted To ER (Admit No Bed)

Percent ALC Days On B-Ward, ICU And ER Admit No Bed

ER Average Length Of Stay For Admitted Patients

Infection Rates

Strategic Goal #1

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• Analysis Period: Q1 2010/11

• Formula/Definition/Source: Hospital Report Patient Satisfaction

• Target: At a minimum higher than the Ontario Community Hospital average and ultimately being the Highest Performer for Ontario.

• Analysis: 31 persons responded representing 43.1% surveyed. Respondents indicated improvement in the following areas: courtesy of admission, how Doctors and nurses worked together and the courtesy of the nurses. The following was noted as areas for improvement: general health teaching related to post discharge instructions and wait time for the call bell to be answered.

• Action: The report and comments are shared with staff. Review the importance of health teaching and materials that are available to assist with patient education. Remind staff of the importance of a timely response to patient’s requests for assistance.

• Responsibility for Monitoring: Acute/CCC Team

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WLMHCommunity Hospitals OntarioHighest Performer Ontario

Patient Overall Satisfaction Rate - Medicine/Surgery

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• Target: At a minimum higher than the Ontario Community Hospital average and ultimately being the Highest Performer for Ontario.

• Analysis: 37 persons responded representing 50% surveyed. WLMH performing at the highest level of satisfaction compared to peers.

• Action: Review patient comments and scores for improvement opportunities.

• Responsibility for Monitoring:Maternal Child and Women’s Health Team

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Patient Overall Satisfaction Rate - Obstetrics

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• Target: At a minimum higher than the Community Hospital average, and ultimately be the Highest Performer for Ontario.

• Analysis: 93 persons responded representing 27.7% surveyed. Response rates for ‘courtesy of doctors and staff’ as well as ‘how well doctors and nurses work together’ exceed the Ontario average. Areas to focus improvement efforts on include wait times and explanation of wait times.

• Action: Develop audit mechanism to measure and evaluate wait time to triage.

• Responsibility for Monitoring: ER Committee and Ambulatory Care Team

Patient Overall Satisfaction Rate - ER

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• Formula/Definition/Source: The average length of stay for Triage 1, 2, 3, 4, and 5 patients. Derived from CIHI NACRS data submissions.

• Formula/Definition/Source: The average length of stay for Triage 1, 2, 3, 4, and 5 patients.

• Target: HAPS/H-SAA• 90% of cases in Triage 1 and 2 with a LOS < 8 hours 90% of

cases in Triage 3 with a LOS < 6 hours and 90% of cases in Triage 5 with a LOS < 4 hours

• Analysis: Length of stay for all triage groupings below HAPS/H-SAA targets

• Action:The ER committee in conjunction with the reports from Decision Support will review the major ambulatory clusters with performance below the desired performance level of 90%.

• Responsibility for Monitoring: ER Committee working with Decision Support.

Average Length of Stay for ER Patients By Triage Level

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Triage 1 & 2Most CritcalTriage 3

Triage 4 & 5

Target

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• Formula/Definition/Source: The percentage of patients seen in ER who left without being seen for Triage 1, 2, 3, 4, and 5 patients. Derived from CIHI NACRS submissions.

• Target: No established LHIN wide target, however discussion has been that 0% should be used for Triage 1, 2 and 3.

• Analysis: WLMH did not meet 0% target for Triage 3, 4 & 5 in Q2 2010.

• Action: The ER committee in conjunction with the reports from Decision Support will review the major ambulatory clusters with performance below the desired performance level of 0%.

• Responsibility for Monitoring: ER Committee working with Decision Support.

ER Patients Left Without Being Seen By Triage Level

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Acute InpatientDay SurgeryHAPS targetLower limit (-10%)Upper limit (+10%)

•Analysis Period: Q2 2010/11

•Formula/Definition/Source: The weighted cases for acute inpatients and day surgical cases for the time period compared to the HAPS agreement volumes.

•Target: Monitor and work towards meeting weighted case volumes in HAPS agreement (720 per quarter plus or minus 10%).

•Analysis: Q2 2010 total weighted cases (acute inpatient and day surgery combined) within target.

•Action: To achieve targets must reduce weighted case volume, review is underway.

•Responsibility for Monitoring: Management

Weighted Case Volume

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Actual Target


•Formula/Definition/Source: The number of patients admitted to the ER as a result of no bed availability or no appropriate bed availability. Derived from MEDITECH monthly census.

•Target: 60 per quarter.

•Analysis: Tracking above target for all quarters trended.

•Action: To achieve targets must try to keep ALC rate down to maintain availability of beds on Medical unit.


Number Of Patients Admitted To ER (Admit No Bed)

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•Formula/Definition/Source: The number of ALC bed days on C-ward, ICU and ER admit no bed expressed as a percentage of patient days for same areas. Derived from MEDITECH daily census and ALC reporting by Discharge Planner.

•Target: MOHLTC provincial target of 11%.

•Analysis: Above provincial target for all periods trended however a significant downward trend is noted from Q1 09 to Q1 10. A 1.0% increase from Q1 10 to Q2 10.

•Action: Continue to monitor appropriateness of admissions, encourage compliance with anticipated date of discharge times and review of ALC designations.


Percent ALC Days On B-Ward, ICU And ER Admit No Bed

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Actual Target


•Formula/Definition/Source: The average number of hours for patients admitted through the ER from the date/time the decision to admit the patient was made to the date/time patient leaves ER. Derived from CIHI NACRS data submissions.

•Target: HNHB LHIN ALC Steering Committee target of < 6 hours.

•Analysis: Above HNHB LHIN target for all quarters trended.

•Action: To achieve target must continue to monitor appropriateness of admissions, encourage compliance with anticipated date of discharge times and continue to work with Community Care Access Centre (CCAC). New initiative, Patient Flow Coordinator, ramping up in January 2011 which should facilitate improvement.


ER Average Length Of Stay For Admitted Patients

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• Formula/Definition/Source: Rate of Infection per 1000 patient days.

• Target: To achieve 0 infection rate.

• Analysis: Achieved target for all agents in Q2.

• Action: Infection Prevention and Control, managers and staff continue diligence in maintaining policies and practices.

• Responsibility for Monitoring: Infection Prevention and Control Committee

Infection Rates

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Infection Rates

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To achieve an active healthy work environmentKey Performance Indicators:

Absenteeism Rate

Overtime Rate

Call-back Rate

Workforce Planning (2)

Performance Appraisal Completion Rate

Strategic Goal #2

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• Formula/Definition/Source: Average number of sick days per person per employment category. Payroll System.

• Target: Reduce total sick time, at a maximum meet the OHA average per person benchmark.

• Analysis: The Service staff group has fallen below the OHA average benchmark. Other areas above the OHA average benchmark. Increase in absenteeism in Nursing/Paramedical for this quarter.

• Action: Managers and Employee Health to review averages for each unit and continue diligence in follow-up with employees

according to Support and Attendance Awareness Program.

• Responsibility for Monitoring: Management

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• Formula/Definition/Source: Actual overtime hours over total budgeted overtime hours x100. Payroll system.

• Target: To meet or achieve under budget status.

• Analysis: Overall overtime is under budget by 7% for the first half of 2010/11. Obstetrics and Switchboard running over budget due to workload and sick time issues.

• Action: Managers and Employee Health continue diligence in follow-up with employees according to Support and Attendance

Awareness Program to reduce regular staffing at overtime rates.

• Responsibility for Monitoring: Management Group 0

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Overtime Rate- Total

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• Formula/Definition/Source: Actual call-back hours over total budgeted call-back hours. Payroll system.

• Target: Budgeted call-back hours.

• Analysis: Exceeding target on a regular basis in Radiology due to increased call-back from ER. Also exceeding targets in the Surgical Suite and Obstetrics due to increase need in Obstetrical surgery.

• Action: Continue to monitor. Review need for night shift in Radiology (only when break even point is met

for costs). • Responsibility for Monitoring:

Management Group

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Call-back Rates

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• Analysis Period: Annual Slide- 2009/10 Calculated at December 31st each year.

• Formula/Definition/Source: Percentage of Nursing/Management staff that have attained age 55, 60 and total over 55 age.

• Target: Not applicable

• Analysis: Increase over last year in total number of staff eligible for retirement in all areas noted. Largest risk in percentage of management staff eligible to retire, small pool of individuals

• Action: Recruit.

• Responsibility for Monitoring: Management

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Workforce Planning

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• Analysis Period: Annual Slide- 2009/10 Calculated at December 31st each year.

• Formula/Definition/Source: Average age and eligibility for retirement of Nursing/Management staff compared to provincial average.

• Target: Not applicable

• Analysis: Large percentage of management staff are eligible to retire, small pool of individuals. Provincial averages not yet available, however WLMH is trending up. WLMH must compete for staffing.

• Action: Continue with development of recruitment

and succession planning strategies.• Responsibility for Monitoring:

Management

Average Age

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Workforce Planning

Percentage over age 55

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• Formula/Definition/Source: The cumulative number of Performance Appraisals completed for the period over the cumulative total number of Performance Appraisals to be completed for the period X 100. Human Resources.

• Target: 100% completion by March 31, 2011

• Analysis: Total completion rate at 66%.

• Action: Each department manager has received an updated spreadsheet indicating completed and outstanding Performance Appraisals with expected date for completion.

• Responsibility for Monitoring: Management Group

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PA Completion Rate Goal

Performance Appraisal Completion Rate

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To maintain strong financial performanceKey Performance Indicators:

Operating Margin

Current Ratio

Strategic Goal #3

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• Formula/Definition/Source: Surplus (deficit) over total income x 100.

• Target: 0% - LHIN expectation is that net margin be 0% or higher.

• Analysis: Year to date, an operating deficit of $391,844 which is an operating margin of -3.56. Budgeted deficit year to date $206,553 which is an operating margin of -2.66.

• Action: Continue work on budget balancing strategies as the LHIN expectation is a balanced budget for 20011/12.


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Total Margin Standard

Operating Margin

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• Formula/Definition/Source: The current assets over current liabilities. Trial Balance submission to the MOHLTC/LHIN.

• Target: 2.63- 3.21 is the MOHLTC standard.

• Analysis: Year to date the current ratio is 1.96 which is under the performance corridor set by the LHIN. It is imperative to maintain a positive working capital as it largely affects the current ratio.


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corporate monitor

Documents

patient care4goal

patient education

review patient comments

highest level of satisfaction

patient flow coordinator

highest performer

patients requests

beder average length