Report on Performance Scorecard
Technical Specification
South West LHIN
February 9, 2016
This document contains technical guidelines for how each indictor on the Report on Performance Scorecard is produced. For
any questions about this document, please email swlhinreporting@lhins.on.ca with ‘ROP’ in the subject line.
Report on Performance Scorecard: Technical Specifications
TABLE OF CONTENTS
REPORT ON PERFORMANCE SCORECARD: TECHNICAL SPECIFICATIONS ............................................................... 2
WAIT TIME FOR SPECIALISTS (WAIT 1) ..................................................................................................................... 4
EMERGENCY VISITS FOR CONDITIONS THAT COULD BE TREATED IN ALTERNATIVE PRIMARY CARE SETTING .......... 6
PERCENT OF DISCHARGE SUMMARIES SENT FROM HOSPITAL TO COMMUNITY CARE PROVIDER WITHIN 48 HOURS 7
ER REVISITS WITHIN 7 DAYS ................................................................................................................................. 10
READMISSIONS WITHIN 30 DAYS FOR SELECTED CASE MIX GROUPS (CMGS) ........................................................ 12
PERCENT OF PEOPLE SEEING PRIMARY CARE PROVIDER WITHIN 7 DAYS OF DISCHARGE FROM HOSPITAL .......... 13
ER VISITS FOR FALLS AMONG SENIORS ................................................................................................................ 15
PRESSURE ULCER RELATED HOSPITALIZATIONS .................................................................................................. 17
HOSPITAL-ASSOCIATED CLOSTRIDIUM DIFFICILE INFECTIONS (CDI) RATE ............................................................. 20
CASES COMPLETED WITHIN PRIORITY TARGETS FOR IMAGING PROCEDURES ...................................................... 21
VARIANCE FROM HBAM EXPECTED COST ............................................................................................................. 23
ALC RATE (INPATIENT DAYS) ................................................................................................................................. 26
GENERAL NOTES ON BIG DOTS............................................................................................................................. 28
BIG DOT 1: INCREASING THE AVAILABILITY OF FAMILY HEALTH CARE .................................................................... 29
BIG DOT 2: REDUCING EMERGENCY ROOM VISITS ................................................................................................ 31
BIG DOT 3: INCREASING AVAILABILITY AND ACCESS TO COMMUNITY SUPPORTS FOR PEOPLE .............................. 33
BIG DOT 3 REFERENCE: ALC RATE ........................................................................................................................ 36
BIG DOT 3 REFERENCE: READMISSIONS FOR SELECTED CASE MIX GROUPS (CMGS) ............................................ 36
BIG DOT 3 REFERENCE: LENGTH OF STAY FOR HIP REPLACEMENT SURGERY....................................................... 36
BIG DOT 3 REFERENCE: LENGTH OF STAY FOR KNEE REPLACEMENT SURGERY ................................................... 36
KEY DRIVER 1: INCREASE THE COMMUNICATION BETWEEN HEALTH CARE PROVIDERS THROUGH SPIRE/HRM ...... 37
KEY DRIVER 2: INCREASE PROVIDERS USING CLINICAL CONNECT ........................................................................ 39
KEY DRIVER 3: INCREASE ORGANIZATIONS USING THE ‘REGIONAL INTEGRATED DECISION SUPPORT SYSTEM’
(2013-14) ............................................................................................................................................................... 41
KEY DRIVER 4: INCREASE THE PROPORTION OF KEY INITIATIVES (P4R, BSO, ATC, P4Q) MEETING LHIN EXPERIENCE
BASED DESIGN CRITERIA ...................................................................................................................................... 43
South West LHIN Balanced Scorecard Technical Specifications
2
Indicator in technical specification
Indicator from Balanced Scorecard
WAIT TIME FOR SPECIALISTS (WAIT 1)
Reduce wait time to specialist from family health care
EMERGENCY VISITS FOR CONDITIONS THAT COULD BE TREATED
IN ALTERNATIVE PRIMARY CARE SETTING
Reduce rate of ER visits best managed elsewhere (per 1,000 population
aged 1-74)
PERCENT OF DISCHARGE SUMMARIES SENT FROM HOSPITAL TO
COMMUNITY CARE PROVIDER WITHIN 48 HOURS
Increase percent of discharge summaries sent from hospital to community
care provider within 48 hours
ER REVISITS WITHIN 7 DAYS
Reduce ER revisit rates within 7 days (per total unscheduled emergency
visits)
READMISSIONS WITHIN 30 DAYS FOR SELECTED CASE MIX
GROUPS (CMGS)
Reduce hospital readmission rate within 30 days for selected CMGs (per
100 discharges for selected CMGs)
PERCENT OF PEOPLE SEEING PRIMARY CARE PROVIDER WITHIN
7 DAYS OF DISCHARGE FROM HOSPITAL
Increase percent of clients seeing family health care provider within 7
days of discharge (from hospital)
ER VISITS FOR FALLS AMONG SENIORS
Reduce rate of ER visits resulting from falls (per 100,000 population aged
65 and over)
PRESSURE ULCER RELATED HOSPITALIZATIONS
Reduce pressure ulcer related hospitalizations (percent of all discharges)
HOSPITAL-ASSOCIATED CLOSTRIDIUM DIFFICILE INFECTIONS
(CDI) RATE
Reduce hospital acquired infection rates (c diff) (per 1,000 patient days)
CASES COMPLETED WITHIN PRIORITY TARGETS FOR IMAGING
PROCEDURES
Increase timeliness of diagnostic services (percent within target)
VARIANCE FROM HBAM EXPECTED COST
Reduce LHIN cost variance (HBAM hospitals) for acute/day surgery and
ER (actual/expected costs)
ALC RATE (INPATIENT DAYS)
Reduce ALC rate (per total inpatient days)
BIG DOT 1: INCREASING THE AVAILABILITY OF FAMILY HEALTH
CARE
Big Dot 1: increasing the availability of family health care
BIG DOT 2: REDUCING EMERGENCY ROOM VISITS
Big Dot 2: reducing emergency room visits
BIG DOT 3: INCREASING AVAILABILITY AND ACCESS TO
COMMUNTIY SUPPORTS FOR PEOPLE
KEY DRIVER 1: INCREASE THE COMMUNICATION BETWEEN
HEALTH CARE PROVIDERS THROUGH SPIRE/HRM
KEY DRIVER 2: INCREASE PROVIDERS USING CLINICAL CONNECT
KEY DRIVER 3: INCREASE ORGANIZATIONS USING THE ‘REGIONAL
INTEGRTATED DECISION SUPPORT SYSTEM’ (2013-14)
KEY DRIVER 4: INCREASE THE PROPORTION OF KEY INITIATIVES
(P4R, BSO, ATC, P4Q) MEETING LHIN EXPERIENCE BASED DESIGN
CRITERIA
Big Dot 3: increasing availability and access to communtiy supports for
people
Key Driver 1: Increase the communication between health care providers
through SPIRE/HRM
Key Driver 2: Increase providers using Clinical Connect
Key Driver 3: Increase organizations using the ‘Regional Integrated
Decision Support System’ (2013-14)
Key Driver 4: Increase the proportion of key initiatives (P4R, BSO, ATC,
P4Q) meeting LHIN Experience Based Design criteria
Note: In some cases, an indicator on the Balanced Scorecard is based on the Ministry of Health and Long-Term Care (MOHLTC) defined technical
specifications. The column on the left in the table above will note the MOHLTC’s name of the indicator and the column on the right notes the name of
the indicator on the Balanced Scorecard.
South West LHIN Balanced Scorecard Technical Specifications
3
WAIT TIME FOR SPECIALISTS (WAIT 1)
INDICATOR DESCRIPTION
INDICATOR NAME
WAIT TIME FOR SPECIALISTS (WAIT 1)
INDICATOR DESCRIPTION
Wait time from the date the specialist received the referral to the consult date
Detailed description of indicator
INDICATOR CLASSIFICATION
Target:
TBD
PERFORMANCE STANDARD
DENOMINATOR
NUMERATOR
Corridor:
TBD
CALCULATION
TBD
DATA SOURCE
TBD
EXCLUSION/INCLUSION
CRITERIA
TBD
CALCULATION
TBD
DATA SOURCE
TBD
EXCLUSION/INCLUSION
CRITERIA
TIMING/FREQUENCY OF
RELEASE
How often, and when, are data
being released?
GEOGRAPHY & TIMING
Includes:
Includes:
TBD
Reported: TBD
Timeliness: TBD
TBD
LEVELS OF COMPARABILITY
TRENDING
South West LHIN Balanced Scorecard Technical Specifications
TBD
4
Years available for trending
LIMITATIONS
TBD
Specific limitations
ADDITIONAL INFORMATION
COMMENTS
Additional information regarding the
calculation, interpretation, data
source, etc.
TBD
REFERENCES
Provide URLs of any key references
E.g. Diabetes in Canada, HTTP://....
TBD
RESPONSIBILITY FOR
REPORTING
TBD
DATE CREATED (YYYY-MM-DD)
2013-05-03
DATE LAST REVIEWED (YYYYMM-DD)
2013-05-03
South West LHIN Balanced Scorecard Technical Specifications
5
EMERGENCY VISITS FOR CONDITIONS THAT COULD BE TREATED IN
ALTERNATIVE PRIMARY CARE SETTING
INDICATOR NAME
EMERGENCY VISITS FOR CONDITIONS THAT COULD BE TREATED IN
ALTERNATIVE PRIMARY CARE SETTING
http://www.health.gov.on.ca/en/pro/programs/ris/docs/emergency_visits_that_could_be_treated_in_alternative_primary_care_set
ting_en.pdf
South West LHIN Balanced Scorecard Technical Specifications
6
PERCENT OF DISCHARGE SUMMARIES SENT FROM HOSPITAL TO
COMMUNITY CARE PROVIDER WITHIN 48 HOURS
INDICATOR DESCRIPTION
Detailed description of indicator
PERCENT OF DISCHARGE SUMMARIES SENT FROM HOSPITAL TO
COMMUNITY CARE PROVIDER WITHIN 48 HOURS
Percentage of patients discharged from hospital for which discharge summaries
are delivered to primary care provider within 48 hours of discharge from
hospital.
INDICATOR CLASSIFICATION
PERFORMANCE STANDARD
Target:
100%
Corridor:
TBD
CALCULATION
Number of patients discharged from hospitals for whom a discharge summary is
sent via Southwest Physician Office Interface to Regional EMR (SPIRE) to
primary care provider within 48 hours of discharge. Number of patients
discharged from hospitals for whom a discharge summary is signed within 48
hours of discharge and due to be sent by fax is also included for Cerner South
hospitals.
DATA SOURCE
SPIRE transactional data and hospital patient registration system (separate
reports from each of the 3 SPIRE hubs: Cerner North, Meditech, and Cerner
South. Reports generated from each of the hubs are emailed to the LHIN each
month.
Includes:
1. South West LHIN acute and post-acute hospital inpatient discharge
summaries sent by SPIRE. Therefore, includes only inpatients whose
primary care provider is enrolled in SPIRE. For Cerner South
hospitals, discharge summaries are also included if they are sent via
fax, regardless of whether or not the physician is enrolled in SPIRE.
NUMERATOR
INDICATOR DESCRIPTION
INDICATOR NAME
Excludes:
1. Discharges from non-South West LHIN hospitals.
2. Inpatient discharge summaries not dictated or transcribed or those
sent to primary care providers by means other than SPIRE (faxes are
included for Cerner South).
3. Discharges of inpatients whose primary care provider is not enrolled
in SPIRE. In the case of Cerner South, faxed summaries are
included.
4. ER patients.
5. Newborns, deaths, and delivery summaries.
CALCULATION
Number of inpatient discharge summaries sent by SPIRE
DE
NO
MI
NA
TO
R
EXCLUSION/INCLUSION
CRITERIA
South West LHIN Balanced Scorecard Technical Specifications
7
DATA SOURCE
EXCLUSION/INCLUSION
CRITERIA
ADDITIONAL INFORMATION
GEOGRAPHY & TIMING
TIMING/FREQUENCY OF
RELEASE
SPIRE transactional data and hospital patient registration system (separate
reports from each of the 3 SPIRE hubs: Cerner North, Meditech, and Cerner
South. Reports generated from each of the hubs are emailed to the LHIN each
month.
Includes:
1. South West LHIN acute and post-acute hospital inpatient discharge
summaries sent by SPIRE. Therefore, includes only inpatients whose
primary care provider is enrolled in SPIRE. For Cerner South, faxed
discharge summaries are included as well, regardless of whether or
not the provider is enrolled in SPIRE.
Excludes:
1. Discharges from non-South West LHIN hospitals.
2. Inpatient discharge summaries not dictated or transcribed or those
sent to primary care providers by means other than SPIRE (faxes are
included for Cerner South).
3. Discharges of inpatients whose primary care provider is not enrolled
in SPIRE. In the case of Cerner South, faxed summaries are
included.
4. ER patients.
5. Newborns, deaths, and delivery summaries.
Reported: Monthly
How often, and when, are data
being released?
Timeliness: Available within five days of the end of month for Cerner North and
within seven days of the end of the month for Cerner South. HPHA Meditech
data is available within 3 days of the end of the month.
LEVELS OF COMPARABILITY
Comparison is possible between South West LHIN hospitals but no comparator
data available beyond the South West LHIN.
TRENDING
Years available for trending
Data are available as of January 2013 for Cerner North, November 2013 for
Cerner South, and February 2014 for Meditech.
LIMITATIONS
Specific limitations
COMMENTS
Additional information regarding the
calculation, interpretation, data
source, etc.
South West LHIN Balanced Scorecard Technical Specifications
Includes only discharges sent by SPIRE (and fax for Cerner South).
Discharge summaries sent by autofax are likely delivered as quickly to primary
care providers as those sent via SPIRE, but transmission date information is not
available for autofax.
Discharge summaries sent to physicians not enrolled are not included either
(except in the case of Cerner South and summaries sent by fax).
Therefore overall percent of discharge summaries sent within 48 hours has to
be estimated from those sent by SPIRE (and fax for Cerner South).
This indicator assumes that the likelihood of completing dictation and
transcription is no different for summaries of patients whose primary care
providers are enrolled in SPIRE than for patients whose primary care providers
are not enrolled. If evidence surfaces that this is not a valid assumption, the
estimate of the overall percentage can be adjusted based on the known percent
of discharges sent via SPIRE and the new information about the
increased/decreased likelihood of completion of non-SPIRE summaries within
48 hours. For example, if the percent of discharge summaries sent by SPIRE is
60% of all discharges and the proportion sent within 48 hours is 30% (Cerner
North, May 2013) and there is no evidence to suggest that non-SPIRE
8
discharges are dictated/transcribed any more quickly than SPIRE discharges,
one can safely assume that overall, 30% discharge summaries are sent within
48 hours. However, if one assumes that non-SPIRE summaries are twice as
likely to be completed within 48 hours, then the overall percent sent within 48
hours is more likely to be 30% of the SPIRE summaries (i.e. 60%) PLUS 60% of
the non-SPIRE summaries (i.e. 40%) or 18% + 24% or 42%.
In April 2014, the SPIRE summaries represented 61.9% of all discharges at
Cerner North hospitals, 35.5% of Cerner South discharges (including fax and
SPIRE), and 42.8% of all discharges at Meditech hospitals.
REFERENCES
Provide URLs of any key references
E.g. Diabetes in Canada, HTTP://....
RESPONSIBILITY FOR
REPORTING
SPIRE hubs (i.e. Cerner North, Meditech, and Cerner South)
DATE CREATED (YYYY-MM-DD)
2013-05-02
DATE LAST REVIEWED (YYYYMM-DD)
2015-02-06
South West LHIN Balanced Scorecard Technical Specifications
9
ER REVISITS WITHIN 7 DAYS
INDICATOR DESCRIPTION
INDICATOR NAME
INDICATOR DESCRIPTION
Detailed description of indicator
ER REVISITS WITHIN 7 DAYS
Rate of repeat emergency visits occurring within 7 days of a previous visit,
presented as a proportion of all unscheduled emergency visits.
INDICATOR CLASSIFICATION
Target:
TBD
PERFORMANCE STANDARD
DENOMINATOR
NUMERATOR
Corridor:
TBD
CALCULATION
Number of unscheduled emergency visits in the reporting quarter that followed
another visit within 7 days
DATA SOURCE
Cancer Care Ontario
Includes:
EXCLUSION/INCLUSION
CRITERIA
Excludes:
1. Scheduled ER visits.
2. Visits associated with a Health Care Number ‘0’, ‘1’.
3. Visits associated with a province of ‘99’ or ‘CA’ who issues Health
Card.
4. Duplicate visits with the same Health Care Number and ER
registration data/time.
CALCULATION
Total number of unscheduled emergency visits in the reporting quarter
DATA SOURCE
Cancer Care Ontario
Includes:
EXCLUSION/INCLUSION
CRITERIA
South West LHIN Balanced Scorecard Technical Specifications
Excludes:
1. Scheduled ER visits.
2. Visits associated with a Health Care Number ‘0’, ‘1’.
3. Visits associated with a province of ‘99’ or ‘CA’ who issues Health
Card.
4. Duplicate visits with the same Health Care Number and ER
registration data/time.
10
TIMING/FREQUENCY OF
RELEASE
GEOGRAPHY & TIMING
How often, and when, are data
being released
E.g. Be as specific as
possible…..data are released
annually in mid-May
LEVELS OF COMPARABILITY
Reported: Monthly
Timeliness: Data available upon request from CCO. Data is lagged
approximately four months (i.e. September data is available in January).
Can compare between hospitals within the South West LHIN and between
LHINs
TRENDING
Data are available as of April 1, 2011 going forward
Years available for trending
LIMITATIONS
Specific limitations
ADDITIONAL INFORMATION
COMMENTS
Additional information regarding the
calculation, interpretation, data
source, etc.
REFERENCES
Provide URLs of any key references
E.g. Diabetes in Canada, HTTP://....
RESPONSIBILITY FOR
REPORTING
CCO
DATE CREATED (YYYY-MM-DD)
2013-05-03
DATE LAST REVIEWED (YYYYMM-DD)
2014-03-27
South West LHIN Balanced Scorecard Technical Specifications
11
READMISSIONS WITHIN 30 DAYS FOR SELECTED CASE MIX GROUPS
(CMGS)
INDICATOR NAME
READMISSIONS WITHIN 30 DAYS FOR SELECTED CASE MIX GROUPS (CMGS)
http://www.health.gov.on.ca/en/pro/programs/ris/docs/readmission_within_30days_selected_cmgs_en.pdf
South West LHIN Balanced Scorecard Technical Specifications
12
PERCENT OF PEOPLE SEEING PRIMARY CARE PROVIDER WITHIN 7
DAYS OF DISCHARGE FROM HOSPITAL
INDICATOR DESCRIPTION
INDICATOR NAME
INDICATOR DESCRIPTION
PERCENT OF PEOPLE SEEING PRIMARY CARE PROVIDER WITHIN 7
DAYS OF DISCHARGE FROM HOSPITAL
Percentage of people discharged from hospital for specific conditions who have
a primary care encounter within 7 days of discharge
Detailed description of indicator
INDICATOR CLASSIFICATION
PERFORMANCE STANDARD
CALCULATION
Target:
100%
Corridor:
TBD
Number of people discharged from hospital for the following conditions that
have a primary care encounter within 7 days of discharge from acute inpatient
stay: cardiac conditions, congestive heart failure, chronic obstructive pulmonary
disease, cerebrovascular accident (i.e., stroke), diabetes, gastrointestinal
disorders, and pneumonia.
NUMERATOR
Data Source(s): Discharge Abstract Database (DAD), CIHI, Claims History
Database (CHDB), MOHLTC, extracted from Health Data Server, MOHLTC,
May 2012.
DATA SOURCE
EXCLUSION/INCLUSION
CRITERIA
Actual calculated rate accessed via:
The Quarterly: Health Care System Quarterly
Reporting for Ministry Senior Management, produced by Health Analytics
Branch, Health System Information Management and Investment Division
Includes:
1. Patients discharged after inpatient stay for the following conditions:
cardiac conditions, congestive heart failure, chronic obstructive
pulmonary disease, cerebrovascular accident (i.e., stroke), diabetes,
gastrointestinal disorders, and pneumonia.
2. First physician visit in office, home, or long-term care home.
DENOMINATOR
Excludes:
1. Follow-up visits made in hospital.
CALCULATION
Number of patients discharged after inpatient stay for the following conditions:
cardiac conditions, congestive heart failure, chronic obstructive pulmonary
disease, cerebrovascular accident (i.e., stroke), diabetes, gastrointestinal
disorders, and pneumonia.
DATA SOURCE
Data Source(s): Discharge Abstract Database (DAD), CIHI, Claims History
Database (CHDB), MOHLTC, extracted from Health Data Server, MOHLTC,
May 2012.
South West LHIN Balanced Scorecard Technical Specifications
13
Actual calculated rate accessed via:
The Quarterly: Health Care System Quarterly
Reporting for Ministry Senior Management, produced by Health Analytics
Branch, Health System Information Management and Investment Division
EXCLUSION/INCLUSION
CRITERIA
Includes:
1. Patients discharged after inpatient stay for the following conditions:
cardiac conditions, congestive heart failure, chronic obstructive
pulmonary disease, cerebrovascular accident (i.e., stroke), diabetes,
gastrointestinal disorders, and pneumonia.
2. First physician visit in office, home, or long-term care home.
ADDITIONAL INFORMATION
GEOGRAPHY & TIMING
Excludes:
1. Follow-up visits made in hospital.
TIMING/FREQUENCY OF
RELEASE
How often, and when, are data
being released?
Reported: Biannually (usually released in February and August).
Timeliness: Data is lagged approximately three quarters (August 2013 release
only contained data up to Q2 2012/13).
LEVELS OF COMPARABILITY
Can compare between LHINs.
TRENDING
Years available for trending
Data are available as of Q3 2010/11going forward.
LIMITATIONS
Specific limitations
Limited to specific conditions (identified above)
Limited to primary care providers participating in QIPs
COMMENTS
Additional information regarding the
calculation, interpretation, data
source, etc.
Requires merging of primary care billing data and hospital data (i.e. DAD) and
therefore is not possible to calculate locally nor on a monthly basis
REFERENCES
Provide URLs of any key references
E.g. Diabetes in Canada, HTTP://....
The Quarterly, Health Analytics Branch, Health System Information
Management and Investment Division. Posted on the Directory of Networks
(DoN)
RESPONSIBILITY FOR
REPORTING
HAB, MOHLTC
DATE CREATED (YYYY-MM-DD)
2013-05-03
DATE LAST REVIEWED (YYYYMM-DD)
2013-09-16
South West LHIN Balanced Scorecard Technical Specifications
14
ER VISITS FOR FALLS AMONG SENIORS
NUMERATOR
INDICATOR DESCRIPTION
INDICATOR NAME
INDICATOR DESCRIPTION
ER VISITS FOR FALLS AMONG SENIORS
Rate of ER visits resulting from falls (per 100,000 population aged 65 and older)
Detailed description of indicator
INDICATOR CLASSIFICATION
PERFORMANCE STANDARD
Target:
TBD
Corridor:
TBD
CALCULATION
Total number of ER visits with a fall reported.
DATA SOURCE
Data Source(s): National Ambulatory Reporting System (NACRS), CIHI
EXCLUSION/INCLUSION
CRITERIA
Includes:
1. Ontario patients (province of residence = ON).
2. ICD10 code in any diagnosis of W00^-W19^ (ICD10 Block = (W00W19) (FALLS).
3. Patient age of 65 and older.
GEOGRAPHY & TIMING
DENOMINATOR
Excludes:
1. Patients transferred from other facilities or hospitals, e.g. long-term
care homes.
CALCULATION
Population aged 65 and older
DATA SOURCE
Data Source(s): Population Estimates and Projections, Statistics Canada &
Ontario Ministry of Finance, distributed by Ontario Ministry of Health and LongTerm Care: IntelliHealth Ontario
EXCLUSION/INCLUSION
CRITERIA
Includes:
1. Residents of chosen geography.
TIMING/FREQUENCY OF
RELEASE
How often, and when, are data
being released
Reported: Quarterly (NACRS), Annually (Population)
Timeliness: NACRS data is released with an approximate four month delay.
Annual population estimates are updated each October.
E.g. Be as specific as
possible…..data are released
South West LHIN Balanced Scorecard Technical Specifications
15
ADDITIONAL INFORMATION
annually in mid-May
LEVELS OF COMPARABILITY
Can compare between sites and LHINs.
TRENDING
Years available for trending
Data are available as of 2001/02 going forward.
LIMITATIONS
Specific limitations
N/A
COMMENTS
Additional information regarding the
calculation, interpretation, data
source, etc.
N/A
REFERENCES
Provide URLs of any key references
E.g. Diabetes in Canada, HTTP://....
Indicator based on MOHLTC indicator http://www.health.gov.on.ca/en/pro/programs/ris/docs/hospitalizations_for_falls_
among_seniors_en.pdf
RESPONSIBILITY FOR
REPORTING
HAB, MOHLTC
DATE CREATED (YYYY-MM-DD)
2013-05-03
DATE LAST REVIEWED (YYYYMM-DD)
2014-07-28
South West LHIN Balanced Scorecard Technical Specifications
16
PRESSURE ULCER RELATED HOSPITALIZATIONS
INDICATOR NAME
PRESSURE ULCER RELATED HOSPITALIZATIONS
INDICATOR DESCRIPTION
Percent of hospitalizations during which a pressure ulcer occurred, either as
the most responsible diagnosis, a post-admit comorbidity and/or a preexisting condition prior to admission
Detailed description of indicator
INDICATOR CLASSIFICATION
Target: TBD
PERFORMANCE STANDARD
DENOMINATOR
NUMERATOR
Corridor: TBD
CALCULATION
Number of hospitalizations with at least one diagnosis of pressure ulcer in
any of the diagnosis fields in the Discharge Abstract Database. Pressure
ulcer was inferred from the ICD 10 codes ranging from L890 to L899
(Stausberg & Keiffer, 2009).
DATA SOURCE
Hospital Discharge Abstract Database, accessed via IntelliHealth “Pressure
Ulcer” query in South West folder of Web Report Studio
EXCLUSION/INCLUSION
CRITERIA
Includes:
CALCULATION
Number of discharges
DATA SOURCE
Hospital Discharge Abstract Database, accessed via IntelliHealth “Pressure
Ulcers” query in South West folder of Web Report Studio
EXCLUSION/INCLUSION
CRITERIA
1.
Hospitalizations with an ICD10 code of L89.0 to L89.9 in any
diagnosis field.
Includes:
1.
All acute hospital discharges.
GEOGRAPHY & TIMING
TIMING/FREQUENCY OF
RELEASE
How often, and when, are data
being released
E.g. Be as specific as
possible…..data are released
annually in mid-May
South West LHIN Balanced Scorecard Technical Specifications
Reported: Monthly
Timeliness: according to updates of DAD in IntelliHealth (scheduled release
of data is lagged 4 months from close of quarter).
17
Comparisons between hospitals and between LHINs.
LEVELS OF COMPARABILITY
TRENDING
Data are available for more than 10 years (see DAD in IntelliHealth)
Years available for trending
LIMITATIONS
None
Specific limitations
Many estimates of prevalence of pressure ulcers are generated through a
point-in-time clinical survey of all patients in a hospital. These surveys,
based on the work of the National Pressure Ulcer Advocacy Panel (NPUAP),
have been published multiple times since 2001 (Amlung et al., 2001) and
have estimated the prevalence of pressure ulcers in acute care hospitals in
Canada between 12.8 and 17% (VanDenKerkhof et al., 2011) and between 2
and 29% in the USA (Salcido & Popescu, 2009). One study based on
routinely collected hospital discharge abstract data in the USA estimated
prevalence of pressure ulcers at 1.43% (Fogarty et al., 2009, p 679).
COMMENTS
Additional information regarding
the calculation, interpretation, data
source, etc.
Both approaches to understanding the prevalence of pressure ulcers
consider the presence of ulcers in all patients, regardless of the reason for
their hospitalization. Both approaches therefore are consistent with the
approach outlined here to include all ulcers in all hospitalizations in
estimating prevalence.
However, the two different sources of data described in the literature present
remarkably different rates. The rate based on clinical surveys is likely more
meaningful clinically whereas the rate based on routinely collected data is
more available for sustainable ongoing monitoring. The gap between the
estimates highlights the differences between what the two data collection
strategies are measuring and suggests that the rates are not comparable.
Targets for performance measured using these technical specifications (i.e.
routinely collected discharge diagnoses data) can therefore not be based on
prevalence estimates based on clinical surveys.
ADDITIONAL INFORMATION
Amlung, S. R., Miller, W.L., Bosley, L. M., (2001) ‘The 1999 National
Pressure Ulcer Prevalence Survey: A Benchmarking Approach’, Advances in
Skin & Wound Care, 14 (6), pp 297-301
REFERENCES
Provide URLs of any key
references E.g. Diabetes in
Canada, HTTP://....
South West LHIN Balanced Scorecard Technical Specifications
Fogerty, M., Guy,J., Barbul, A., Nanney, L.B., Abumrad, N.N. (2009) ‘African
Americans show increased risk for pressure ulcers: A retrospective analysis
of acute care hospitals in America’ Wound Rep Reg, 17, pp 678–684
Salcido R; Popescu A (2009) ‘Pressure Ulcers and Wound Care’ ,Available
from: http://emedicine.medscape.com/article/319284-overview), (Accessed
Apr 7, 2013)
Stausberg, J., Kiefer, E. (2009) ‘Classification of Pressure Ulcers: A
18
Systematic Literature Review’, Stud Health Technol Inform.146 pp.511-5.
VanDenKerkhof, E.G., Friedberg, E., Harrison, M.B. (2011) ‘Prevalence and
Risk of Pressure Ulcers in Acute Care Following Implementation of Practice
Guidelines: Annual Pressure Ulcer Prevalence Census 1994–2008’, Journal
for Healthcare Quality, 33(5), pp 58–67
RESPONSIBILITY FOR
REPORTING
DATE CREATED (YYYY-MM-DD)
2013-04-09
DATE LAST REVIEWED (YYYYMM-DD)
2013-09-16
South West LHIN Balanced Scorecard Technical Specifications
19
HOSPITAL-ASSOCIATED CLOSTRIDIUM DIFFICILE INFECTIONS (CDI) RATE
INDICATOR NAME
HOSPITAL-ASSOCIATED CLOSTRIDIUM DIFFICILE INFECTIONS (CDI) RATE
http://www.health.gov.on.ca/en/pro/programs/ris/docs/hospital_associated_clostridium_difficile_infections_rate_en.pdf
South West LHIN Balanced Scorecard Technical Specifications
20
INDICATOR DESCRIPTION
CASES COMPLETED WITHIN PRIORITY TARGETS FOR IMAGING
PROCEDURES
INDICATOR NAME
CASES COMPLETED WITHIN PRIORITY TARGETS FOR IMAGING
PROCEDURES
INDICATOR DESCRIPTION
http://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_completed_within_
priority_for_computed_tomography_scans_en.pdf
Detailed description of indicator
http://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_completed_within_
priority_for_mri_scans_en.pdf
INDICATOR CLASSIFICATION
Target:
TBD
PERFORMANCE STANDARD
NUMERATOR
Corridor:
TBD
CALCULATION
Wait Days = Procedure Date – Decision to Treat Date – Patient Unavailable
Days
DATA SOURCE
iPort
Includes:
1.
EXCLUSION/INCLUSION
CRITERIA
2.
DENOMINATOR
3.
4.
5.
6.
CALCULATION
N/A
DATA SOURCE
N/A
EXCLUSION/INCLUSION
CRITERIA
N/A
South West LHIN Balanced Scorecard Technical Specifications
Closed cases submitted by hospitals through the Wait Time
Information System (WTIS)
Metrics: Completed Cases <= Access Target, Completed Case
Volume: MRI/CT, % Cases Completed Within Access Target: MRI/CT
Attributes: LHIN
Service Area = MRI and CT
Priority 2, 3, 4, Unknown and Not Applicable
Patients aged 18 years and older
21
GEOGRAPHY & TIMING
TIMING/FREQUENCY OF
RELEASE
How often, and when, are data
being released?
LEVELS OF COMPARABILITY
Reported: Quarterly
Timeliness: Data released at the end of the months in April, July, October and
January.
Can compare between LHINs and between hospitals but not between primary
care providers
TRENDING
Data are available from June 2007
Years available for trending
LIMITATIONS
Specific limitations
Wait times data submission is voluntary. Hospitals not reporting cases promptly
are excluded at the time of data extraction.
ADDITIONAL INFORMATION
COMMENTS
Additional information regarding the
calculation, interpretation, data
source, etc.
REFERENCES
https://www.cancercare.on.ca/ocs/wait-times/wtio/
Provide URLs of any key references
E.g. Diabetes in Canada, HTTP://....
RESPONSIBILITY FOR
REPORTING
Hospitals
DATE CREATED (YYYY-MM-DD)
2013-05-03
DATE LAST REVIEWED (YYYYMM-DD)
2014-07-28
South West LHIN Balanced Scorecard Technical Specifications
22
INDICATOR DESCRIPTION
VARIANCE FROM HBAM EXPECTED COST
INDICATOR NAME
VARIANCE FROM HBAM EXPECTED COST
INDICATOR DESCRIPTION
Ratio between actual cost per unit of service and HBAM expected cost (average
of the ratio for all HBAM hospitals – each component calculated separately)
Detailed description of indicator
INDICATOR CLASSIFICATION
PERFORMANCE STANDARD
CALCULATION
Target: 1.00
Corridor: TBD
Ratio of difference between actual expenditure per unit of service for each of
the components of the HBAM formulae and the expected cost for each
component which is generated annually via HBAM formulae.
Actual expenditure per unit of service: total direct nursing costs plus a
proportion of indirect costs as reported in each hospital’s quarterly trial balance
(generated quarterly by Scott Chambers or delegate)
‘
Proportion of indirect costs inferred from the allocation of indirect costs to each
HBAM component for the previous fiscal year in the annual financial summary
provided by the MOHLTC based on the cumulative trial balances submitted
through the year.
NUMERATOR
Units of service: weighted cases for Acute (DAD), Day Surgery and ER
components (NACRS), weighted cases for CCC, Rehab and MH (sources are
CCRS, NRS and MH inpatient data but not currently being accessed because it
is too old for use in scorecard – revisit sourcing from RIDS end of Q3 13/14)
Includes:
1. All clinical activity in functional centres associated with Acute
Inpatient, Day Surgery, CCC, Rehab, ER and inpatient MH as per the
linked document.
EXCLUSION/INCLUSION
CRITERIA
OCDM
Guide_13-14YE_Final May 2014.pdf
2.
All hospitals included by HBAM methodology – as of May 2014, there
are 7: London Health Sciences Centre, Grey Bruce Health ServicesOwen Sound, Stratford General Hospital, Woodstock General
Hospital, St Thomas Elgin General Hospital, St Joseph’s Health Care,
and Strathroy Middlesex General Hospital.
Excludes
1.
2.
South West LHIN Balanced Scorecard Technical Specifications
All non-HBAM hospitals
All clinical activity in functional centres other than those specified
23
DENOMINATOR
above
CALCULATION
The expected cost per unit of service generated annually based on HBAM
formulae for each component (e.g. Acute and Day surgery, ER, etc.)
DATA SOURCE
Annual HBAM calculations from MOHLTC
EXCLUSION/INCLUSION
CRITERIA
Includes:
1. All clinical activity in functional centres associated with Acute
Inpatient, Day Surgery, CCC, Rehab, ER and inpatient MH (see
above for detail)
2. All hospitals included by HBAM methodology (see above for detail)
Excludes
1.
2.
All non-HBAM hospitals
All clinical activity in functional centres other than those specified
above
GEOGRAPHY & TIMING
TIMING/FREQUENCY OF
RELEASE
How often, and when, are data
being released
E.g. Be as specific as
possible…..data are released
annually in mid-May
Reported: quarterly for Q2, Q3 and Q 4 only (no update possible for Q1 as no
trial balance ever submitted for Q1)
Timeliness: data submitted by the 7th of the 2nd month following the quarter end
(i.e. Q3 ends in December, data submitted by February 7th).
LEVELS OF COMPARABILITY
Comparisons between HSPs within SW LHIN only because we have no access
to trial balance in other LHINS.
TRENDING
Years available for trending
Data are available as of 2010 forward
ADDITIONAL INFORMATION
Limited to HBAM hospitals (see above for detail).
Not possible to drill down below level of HBAM component (e.g. Acute/day
surgery, CCC, etc.) to understand contributing factors to changes (or lack
thereof) in performance
LIMITATIONS
Specific limitations
South West LHIN Balanced Scorecard Technical Specifications
Actual cost per unit of service is calculated internally by the South West LHIN
based on the hospital’s previous year’s distribution of indirect costs between
HBAM components. For example, the amount of laboratory costs attributed to
CCC patients divided by the direct costs for CCC patients (e.g. nursing costs) is
used to determine how much laboratory costs to attribute to the quarterly total
direct nursing costs for CCC to estimate the actual cost per unit of CCC service.
It is possible that the allocation used to distribute indirect costs to various HBAM
components in the current year is not the same as that used in the previous
24
year. However, there is no current data on the distribution and this is the
distribution used by MOHLTC throughout the year so it is rational to use this in
these calculations.
COMMENTS
Additional information regarding the
calculation, interpretation, data
source, etc.
REFERENCES
Provide URLs of any key references
E.g. Diabetes in Canada, HTTP://....
RESPONSIBILITY FOR
REPORTING
The goal is to decrease the variance to achieve a ratio of 1 or less (i.e. actual
cost is less than expected).
References available on the Health Data Branch web portal (hsimi.on.ca)
Health Service Providers
DATE CREATED (YYYY-MM-DD)
2013-05-02
DATE LAST REVIEWED (YYYYMM-DD)
2014-06-03
South West LHIN Balanced Scorecard Technical Specifications
25
INDICATOR DESCRIPTION
ALC RATE (INPATIENT DAYS)
INDICATOR NAME
ALC RATE (INPATIENT DAYS)
INDICATOR DESCRIPTION
Reports on ALC patients that are still waiting in a hospital bed (open) and ALC
patients that have been discharged/discontinued (closed) during the time
period.
Detailed description of indicator
INDICATOR CLASSIFICATION
Target:
TBD
PERFORMANCE STANDARD
NUMERATOR
Corridor:
TBD
CALCULATION
The total ALC days represents the total number of ALC days contributed by
ALC patients within the specific reporting month/quarter. Inpatient service type
is identified in the WTIS.
ALC days for Inpatient Services NS + SU + IC
DATA SOURCE
WTIS-ALC Data Cut
EXCLUSION/INCLUSION
CRITERIA
Excludes:
1. Hospitals that do not report to both the WTIS and the BCS
2. Inpatient days in “Emergency room” bed type
3. ALC cases discontinued due to ‘Data Entry Error’.
4. ALC cases having Inpatient Service = Discharge Destination for PostAcute Care (*Exception: Bloorview Rehab, CCC to CCC).
5. ALC cases identified by the facility for exclusion.
CALCULATION
The total patient days represents the total number of patient days contributed by
inpatients within the specific reporting month/quarter. Bed type is identified in
the BCS data submission. Acute Patient days = Med + Surg + CMS + ICU +
OBS + PAE + Pediatrics in Nursery + Newborns
DENOMINATOR
Bed Census Summary (BCS) [previously the Daily Census Summary (DCS)].
DATA SOURCE
Ontario hospitals make monthly data submissions to the ministry’s Health Data
Branch (HDB) Web Portal. ATC then takes a data cut from the Web Portal to
use for the total patient days in the ALC Rate Report.
EXCLUSION/INCLUSION
CRITERIA
Excludes:
South West LHIN Balanced Scorecard Technical Specifications
Patient days contributed by inpatients in the emergency department (Bed Type
26
= Emergency)
TIMING/FREQUENCY OF
RELEASE
Reported: Quarterly
GEOGRAPHY & TIMING
How often, and when, are data
being released
Timeliness: 6th business day following the last reporting month in the quarter
E.g. Be as specific as
possible…..data are released
annually in mid-May
LEVELS OF COMPARABILITY
Can compare between hospitals within the South West LHIN and between
LHINs
TRENDING
Data are available as of July 2011
Years available for trending
LIMITATIONS
Limited to hospitals reporting into WTIS and BCS.
Specific limitations
Methodology Notes from Supplemental Material for the Quarterly Stocktake
Report (produced by CCO) (basis for this technical specification)
COMMENTS
The day of ALC designation is counted as an ALC day but the date of discharge
or discontinuation is not counted as an ALC day.
Additional information regarding the
calculation, interpretation, data
source, etc.
For cases with an ALC designation date on the last day of a reporting period
and no discharge/discontinuation date, then ALC days = 1.
The ALC Rate indicator methodology makes the assumption that the Inpatient
Service data element (as defined in the WTIS) is comparable to the Bed Type
data element (as defined in the BCS).
REFERENCES
ADDITIONAL INFORMATION
Provide URLs of any key references
E.g. Diabetes in Canada, HTTP://....
Supplemental Material for the Quarterly Stocktake Report can be found on the
Directory of Networks (DoN), within the Quarterly Performance and Stocktake
Reports folder.
RESPONSIBILITY FOR
REPORTING
CCO via Stocktake supplemental report
DATE CREATED (YYYY-MM-DD)
2013-05-03
DATE LAST REVIEWED (YYYYMM-DD)
2013-09-16
South West LHIN Balanced Scorecard Technical Specifications
27
General Notes on Big Dots
1) Targets for Big Dots were set in Fall 2012 based on data available at that time.
2) The following principles were used to define targets:
a. Big Dot 1: 14% increase over baseline rate (2012/13) of patients discharged from hospital seen by
family physician within 7 days of discharge.
b. Big Dot 2: 5% reduction from baseline rate (2011/12) in ER revisits within 7 days, per HQO and
MOHLTC approach to setting targets for improvements and given that there are no other existing
targets for this indicator.
c. Big Dot 3: reduction in ALC days from baseline rate (2011/12) to MLPA target, elimination of the
gap between actual and expected readmission rates for selected CMGs, and 5% reduction in LOS
in hip and knee surgery from baseline rate (2011/12). Note: in February 2014, the decision was
made to move from ALC days to ALC rate as ALC rate includes acute and post-acute. The target,
however, was not changed.
3) Progress on Big Dots is measured from Q1 2013/14 going forward since that is the time period for the IHSP
initiative, which the Big Dots are intended to track the impact of.
4) Progress on Big Dots is measured as cumulative improvement over baseline performance. Baseline
performance is either the MLPA baseline for 2013/14 or, if not available, the most recent 4 quarters of data
available as of Apr 2013. In the case of Big Dot 1, baseline was reset to 2012/13 when 2013/14 data was
made available. This means that the baseline period is not the same for all components of the Big Dots. It
also means that baseline will not be the performance level at the time the target was calculated. This is
because changes in performance between the time the target was calculated and April 2013 should not be
attributed to progress with the new IHSP because the IHSP was first launched in April 2013, not prior to
that.
5) Unlike reporting on most of the other Scorecard indicators, progress on Big Dots will NOT be measured on
the data available during the time period of interest but rather on the data that describe that time period.
Another difference is that progress on Big Dots is cumulative over each following time period rather than
being point estimates for performance at a particular time. For example, if there were 100 revisits prevented
in Q1 and 250 in Q2, the progress on this Big Dot would be reported as 350 on whatever date that Q2 data
were available, which could be Q4 or later.
6) The process for calculating progress on Big Dots is detailed in the following technical specifications.
South West LHIN Balanced Scorecard Technical Specifications
28
INDICATOR DESCRIPTION
BIG DOT 1: INCREASING THE AVAILABILITY OF FAMILY HEALTH CARE
INDICATOR NAME
INDICATOR DESCRIPTION
Detailed description of indicator
BIG DOT 1: INCREASING THE AVAILABILITY OF FAMILY HEALTH CARE
Cumulative total of the number of patients seen by primary care provider within
7 days of discharge from inpatient stay for specific conditions
INDICATOR CLASSIFICATION
PERFORMANCE STANDARD
CALCULATION
Target: 14% improvement over baseline
Corridor: n/a
Number of people discharged from hospital for the following conditions that
have a primary care encounter within 7 days of discharge from acute inpatient
stay: 25 CMGs covering cardiac conditions, congestive heart failure, chronic
obstructive pulmonary disease, cerebrovascular accident (i.e., stroke), diabetes,
gastrointestinal disorders, and pneumonia.
NUMERATOR
Data Source(s): Discharge Abstract Database (DAD), CIHI, Claims History
Database (CHDB), MOHLTC, extracted from Health Data Server, MOHLTC,
May 2012.
DATA SOURCE
EXCLUSION/INCLUSION
CRITERIA
Actual calculated rate accessed via:
The Quarterly: Health Care System Quarterly
Reporting for Ministry Senior Management, produced by Health Analytics
Branch, Health System Information Management and Investment Division
Includes:
1. Patients discharged after inpatient stay for the following conditions:
cardiac conditions, congestive heart failure, chronic obstructive
pulmonary disease, cerebrovascular accident (i.e., stroke), diabetes,
gastrointestinal disorders, and pneumonia.
2. First physician visit in office, home, or long-term care home.
GEOGRAPHY &
TIMING
DENOMINATOR
Excludes:
1. Follow-up visits made in hospital.
CALCULATION
TBD
DATA SOURCE
TBD
EXCLUSION/INCLUSION
CRITERIA
TBD
TIMING/FREQUENCY OF
RELEASE
How often, and when, are data
South West LHIN Balanced Scorecard Technical Specifications
Reported: Biannually
Timeliness: Data is lagged approximately three quarters (August 2013 release
only contained data up to Q2 2012/13).
29
being released
ADDITIONAL INFORMATION
E.g. Be as specific as
possible…..data are released
annually in mid-May
LEVELS OF COMPARABILITY
Not comparable to anything (i.e. no cross-LHIN data)
TRENDING
Years available for trending
Data are available as of Q3 2010/11going forward.
LIMITATIONS
Specific limitations
Limited to specific conditions (identified above)
Limited to primary care providers participating in QIPs
COMMENTS
Additional information regarding the
calculation, interpretation, data
source, etc.
Requires merging of primary care billing data and hospital data (i.e. DAD) and
therefore is not possible to calculate locally nor on a monthly basis
REFERENCES
Provide URLs of any key references
E.g. Diabetes in Canada, HTTP://....
The Quarterly, Health Analytics Branch, Health System Information
Management and Investment Division. Posted on the Directory of Networks
(DoN)
RESPONSIBILITY FOR
REPORTING
HAB, MOHLTC
DATE CREATED (YYYY-MM-DD)
2013-05-03
DATE LAST REVIEWED (YYYYMM-DD)
2014-11-24
South West LHIN Balanced Scorecard Technical Specifications
30
INDICATOR DESCRIPTION
BIG DOT 2: REDUCING EMERGENCY ROOM VISITS
INDICATOR NAME
INDICATOR DESCRIPTION
INDICATOR CLASSIFICATION
CALCULATION
NUMERATOR
Cumulative total of revisits reduced through reduction the % of ER revisits
within 7 days (based on ER REVISITS WITHIN 7 DAYS)
Detailed description of indicator
PERFORMANCE STANDARD
DENOMINATOR
BIG DOT 2: REDUCING EMERGENCY ROOM VISITS
Target: 15,000 visits prevented from April 1, 2013 to March 31, 2016
Corridor: n/a
The difference between the current and baseline ER revisit rate multiplied by
the total number of ER visits (not revisits) in the current quarter (i.e. (Q1RateBaseline)/Total Q1 ER Visits)
The number of revisits prevented in a quarter is added to the revisits prevented
in previous quarters to generate a cumulative total from baseline forwards.
DATA SOURCE
See ER REVISITS WITHIN 7 DAYS
EXCLUSION/INCLUSION
CRITERIA
See ER REVISITS WITHIN 7 DAYS
CALCULATION
N/A
DATA SOURCE
N/A
EXCLUSION/INCLUSION
CRITERIA
N/A
TIMING/FREQUENCY OF
RELEASE
How often, and when, are data
being released
Reported: Quarterly
GEOGRAPHY & TIMING
Timeliness: see ER REVISITS WITHIN 7 DAYS
E.g. Be as specific as
possible…..data are released
annually in mid-May
LEVELS OF COMPARABILITY
Not comparable to any other LHIN
TRENDING
Years available for trending
See ER RE-VISITS WITHIN 7 DAYS OF ER VISITS
South West LHIN Balanced Scorecard Technical Specifications
31
ADDITIONAL INFORMATION
LIMITATIONS
Specific limitations
See ER RE-VISITS WITHIN 7 DAYS OF ER VISITS
COMMENTS
Additional information regarding the
calculation, interpretation, data
source, etc.
Target was set on the basis of a 5% reduction in revisits for 3 years over the
2010/11 rate.
REFERENCES
Provide URLs of any key references
E.g. Diabetes in Canada, HTTP://....
RESPONSIBILITY FOR
REPORTING
See ER RE-VISITS WITHIN 7 DAYS
DATE CREATED (YYYY-MM-DD)
2013-05-03
DATE LAST REVIEWED (YYYYMM-DD)
2013-09-16
South West LHIN Balanced Scorecard Technical Specifications
32
BIG DOT 3: INCREASING AVAILABILITY AND ACCESS TO COMMUNITY
SUPPORTS FOR PEOPLE
INDICATOR DESCRIPTION
INDICATOR NAME
INDICATOR DESCRIPTION
Detailed description of indicator
BIG DOT 3: INCREASING AVAILABILITY AND ACCESS TO COMMUNTIY
SUPPORTS FOR PEOPLE
Cumulative total of hospitalization days reduced through reduction of ALC rate,
reduced readmissions for selected CMGs, and reduced length of stay for total
hip/knee joint replacements (total joint replacements)
INDICATOR CLASSIFICATION
PERFORMANCE STANDARD
Target: 17,000 or 36,000 days saved from April 1, 2013 to March 31, 2016 (see
comments below)
Corridor: n/a
ALC
The difference between the current and baseline ALC rate multiplied by the total
inpatient days (not ALC days) in the current quarter. Baseline is established as
the 2012/13 fiscal year.
READMISSIONS
NUMERATOR
The number of hospitalizations prevented is the difference in the gap between
the expected and actual readmission rates relative to the baseline gap
multiplied by the total number of index visits in the current quarter (see
READMISSIONS FOR SELECTED CASE MIX GROUPS (CMGs)). Multiply the
number of hospitalizations by the average LOS for these CMGs (10.8 days circa
calculation of the target) to generate the number of days prevented.
CALCULATION
(Current gap – baseline gap) * current index cases * average LOS at baseline =
additional readmits prevented through improvements over baseline in
readmission rate
LOS FOR HIP/KNEE TOTAL JOINT REPLACEMENTS (TJR)
The difference between the current and baseline average LOS for hip/knee TJR
is multiplied by the total number of discharges for hip/knee TJR in the current
quarter. Baseline will be set as the average LOS for 2012/13 when it becomes
available. For interim reporting of progress (i.e. prior to availability of 2013/14
data), baseline is set as average LOS for 2011/12.
CUMULATIVE TOTAL
The number of hospitalization days prevented in a quarter is added to the days
prevented in previous quarters to generate a cumulative total from baseline
forwards.
DATA SOURCE
South West LHIN Balanced Scorecard Technical Specifications
See each of the source indicators (i.e. ALC rate, readmissions and hip/knee
joint replacement)
33
DENOMINATOR
EXCLUSION/INCLUSION
CRITERIA
See each of the source indicators (i.e. ALC rate, readmissions and hip/knee
joint replacement)
CALCULATION
n/a
DATA SOURCE
n/a
EXCLUSION/INCLUSION
CRITERIA
n/a
TIMING/FREQUENCY OF
RELEASE
GEOGRAPHY & TIMING
Reported: Quarterly
How often, and when, are data
being released
E.g. Be as specific as
possible…..data are released
annually in mid-May
LEVELS OF COMPARABILITY
TRENDING
Years available for trending
LIMITATIONS
Specific limitations
Timeliness: See each of the source indicators (i.e.ALC Rate, Readmissions for
Selected Case Mix Groups, and Wait Times for Hip/Knee Replacement
Surgery)
Not comparable to any other LHIN
See each of the source indicators (i.e. ALC Rate, Readmissions for Selected
Case Mix Groups, and Wait Times for Hip/Knee Replacement Surgery)
See each of the source indicators (i.e. ALC Rate, Readmissions for Selected
Case Mix Groups, and Wait Times for Hip/Knee Replacement Surgery)
COMMENTS
Additional information regarding the
calculation, interpretation, data
source, etc.
ADDITIONAL INFORMATION
REFERENCES
Provide URLs of any key references
E.g. Diabetes in Canada, HTTP://....
RESPONSIBILITY FOR
REPORTING
See each of the source indicators (i.e. ALC Rate, Readmissions for Selected
Case Mix Groups, and Wait Times for Hip/Knee Replacement Surgery)
DATE CREATED (YYYY-MM-DD)
2013-05-03
South West LHIN Balanced Scorecard Technical Specifications
34
DATE LAST REVIEWED (YYYYMM-DD)
South West LHIN Balanced Scorecard Technical Specifications
2014-02-26
35
BIG DOT 3 REFERENCE: ALC RATE
INDICATOR NAME
ALC RATE
See ALC Rate definition above.
BIG DOT 3 REFERENCE: READMISSIONS FOR SELECTED CASE MIX
GROUPS (CMGS)
INDICATOR NAME
READMISSIONS FOR SELECTED CASE MIX GROUPS (CMGS)
See Readmissions for Selected Case Mix Groups (CMGs) definition above.
BIG DOT 3 REFERENCE: LENGTH OF STAY FOR HIP REPLACEMENT
SURGERY
INDICATOR NAME
LENGTH OF STAY FOR HIP REPLACEMENT SURGERY
Based on the cohorts developed from the Quality Based Procedures Handbook.
QBP Clinical
Handbook Primary Unilateral Hip Replacement (06-19-2012) Final.pdf
BIG DOT 3 REFERENCE: LENGTH OF STAY FOR KNEE REPLACEMENT
SURGERY
Based on the cohorts developed from the Quality Based Procedures Handbook.
QBP Clinical
Handbook Primary Unilateral Knee Replacement (06-19-2012) Final.pdf
South West LHIN Balanced Scorecard Technical Specifications
36
DENOMINATOR
NUMERATOR
INDICATOR DESCRIPTION
KEY DRIVER 1: INCREASE THE COMMUNICATION BETWEEN HEALTH
CARE PROVIDERS THROUGH SPIRE/HRM
INDICATOR NAME
INDICATOR DESCRIPTION
Detailed description of indicator
KEY DRIVER 1: INCREASE THE COMMUNICATION BETWEEN HEALTH
CARE PROVIDERS THROUGH SPIRE/HRM
Proportion of South West LHIN clinicians enrolled in SPIRE/HRM
INDICATOR CLASSIFICATION
PERFORMANCE STANDARD
Target:
Corridor:
CALCULATION
Number of South West LHIN nurse practitioners and primary care physicians
enrolled in SPIRE/HRM
DATA SOURCE
Data provided by the South West LHIN eHealth team each quarter.
EXCLUSION/INCLUSION
CRITERIA
Includes:
1. Primary care physicians and nurse practitioners in the South West
LHIN
CALCULATION
Number of South West LHIN nurse practitioners and primary care physicians
DATA SOURCE
Data provided by the South West LHIN eHealth team each quarter.
EXCLUSION/INCLUSION
CRITERIA
Includes:
1. Primary care physicians and nurse practitioners in the South West
LHIN
GEOGRAPHY & TIMING
TIMING/FREQUENCY OF
RELEASE
How often, and when, are data
being released
Reported: Upon request
E.g. Be as specific as
possible…..data are released
annually in mid-May
LEVELS OF COMPARABILITY
South West LHIN Balanced Scorecard Technical Specifications
37
TRENDING
Years available for trending
LIMITATIONS
Represents a point in time number.
Specific limitations
ADDITIONAL INFORMATION
COMMENTS
Additional information regarding the
calculation, interpretation, data
source, etc.
REFERENCES
Provide URLs of any key references
E.g. Diabetes in Canada, HTTP://....
RESPONSIBILITY FOR
REPORTING
DATE CREATED (YYYY-MM-DD)
2014-02-26
DATE LAST REVIEWED (YYYYMM-DD)
2014-02-26
South West LHIN Balanced Scorecard Technical Specifications
38
DENOMINATOR
NUMERATOR
INDICATOR DESCRIPTION
KEY DRIVER 2: INCREASE PROVIDERS USING CLINICAL CONNECT
INDICATOR NAME
INDICATOR DESCRIPTION
Detailed description of indicator
KEY DRIVER 2: INCREASE PROVIDERS USING CLINICAL CONNECT
Proportion of South West LHIN providers using Clinical Connect
INDICATOR CLASSIFICATION
PERFORMANCE STANDARD
Target:
Corridor:
CALCULATION
Number of South West LHIN providers using Clinical Connect
DATA SOURCE
Data provided by the South West LHIN eHealth team each quarter.
EXCLUSION/INCLUSION
CRITERIA
Includes:
1. Providers using Clinical Connect in the South West LHIN
CALCULATION
Number of South West LHIN providers
DATA SOURCE
Data provided by the South West LHIN eHealth team each quarter.
EXCLUSION/INCLUSION
CRITERIA
Includes:
1. Providers in the South West LHIN
GEOGRAPHY & TIMING
TIMING/FREQUENCY OF
RELEASE
How often, and when, are data
being released
Reported: Upon request
E.g. Be as specific as
possible…..data are released
annually in mid-May
LEVELS OF COMPARABILITY
TRENDING
Years available for trending
South West LHIN Balanced Scorecard Technical Specifications
39
LIMITATIONS
Represents a point in time number.
Specific limitations
ADDITIONAL INFORMATION
COMMENTS
Additional information regarding the
calculation, interpretation, data
source, etc.
REFERENCES
Provide URLs of any key references
E.g. Diabetes in Canada, HTTP://....
RESPONSIBILITY FOR
REPORTING
DATE CREATED (YYYY-MM-DD)
2014-02-26
DATE LAST REVIEWED (YYYYMM-DD)
2014-02-26
South West LHIN Balanced Scorecard Technical Specifications
40
DENOMINATOR
NUMERATOR
INDICATOR DESCRIPTION
KEY DRIVER 3: INCREASE ORGANIZATIONS USING THE ‘REGIONAL
INTEGRATED DECISION SUPPORT SYSTEM’ (2013-14)
INDICATOR NAME
INDICATOR DESCRIPTION
Detailed description of indicator
KEY DRIVER 3: INCREASE ORGANIZATIONS USING THE ‘REGIONAL
INTEGRATED DECISION SUPPORT SYSTEM’ (2013-14)
Proportion of eligible South West LHIN health service providers (currently
hospitals and the CCAC) with all data submissions up to date in the Regional
Integrated Decision Support (RIDS) system.
INDICATOR CLASSIFICATION
PERFORMANCE STANDARD
Target:
Corridor:
CALCULATION
Number of South West LHIN health service providers with all data submissions
up to date as denoted by ‘Up to Date’ submissions on the Submissions tab of
IDS.
DATA SOURCE
Data pulled by Lindsey Declercq after the last data upload (Wednesday nights)
before the Scorecard is due to be released.
EXCLUSION/INCLUSION
CRITERIA
Includes:
1. Providers submitting data to RIDS in the South West LHIN (currently
all hospitals and the CCAC).
CALCULATION
Number of South West LHIN health service providers submitting data to RIDS
(currently all hospitals and the CCAC).
DATA SOURCE
Data pulled from RIDS
EXCLUSION/INCLUSION
CRITERIA
Includes:
1. Providers submitting data to RIDS in the South West LHIN (currently
all hospitals and the CCAC).
GEOGRAPHY & TIMING
TIMING/FREQUENCY OF
RELEASE
How often, and when, are data
being released
Reported: Data can be accessed as frequently as desired.
E.g. Be as specific as
possible…..data are released
annually in mid-May
LEVELS OF COMPARABILITY
South West LHIN Balanced Scorecard Technical Specifications
41
TRENDING
Years available for trending
LIMITATIONS
Represents a point in time number.
Specific limitations
ADDITIONAL INFORMATION
COMMENTS
Additional information regarding the
calculation, interpretation, data
source, etc.
REFERENCES
Provide URLs of any key references
E.g. Diabetes in Canada, HTTP://....
RESPONSIBILITY FOR
REPORTING
DATE CREATED (YYYY-MM-DD)
2014-02-26
DATE LAST REVIEWED (YYYYMM-DD)
2014-03-14
South West LHIN Balanced Scorecard Technical Specifications
42
GEOGRAPHY & TIMING
DENOMINATOR
NUMERATOR
INDICATOR DESCRIPTION
KEY DRIVER 4: INCREASE THE PROPORTION OF KEY INITIATIVES (P4R,
BSO, ATC, P4Q) MEETING LHIN EXPERIENCE BASED DESIGN CRITERIA
INDICATOR NAME
INDICATOR DESCRIPTION
Detailed description of indicator
KEY DRIVER 4: INCREASE THE PROPORTION OF KEY INITIATIVES (P4R,
BSO, ATC, P4Q) MEETING LHIN EXPERIENCE BASED DESIGN CRITERIA
Number of criteria met by Pay For Results, Behavioural Supports Ontario,
Access To Care, and Partnering For Quality
INDICATOR CLASSIFICATION
PERFORMANCE STANDARD
Target:
Corridor:
CALCULATION
Number of criteria met by Pay For Results, Behavioural Supports Ontario,
Access To Care, and Partnering For Quality
DATA SOURCE
Data requested from each of the Project Leads by Nicole Robinson
EXCLUSION/INCLUSION
CRITERIA
Criteria Includes:
1. Continuous plans to capture patient experience
2. Continuous incorporation of patient experience feedback
3. Actively engaged patients involved in co-designing improvements
4. Continuous implementation of co-design improvement opportunities
5. Communication, monitoring, and reporting of patient experience
6. Spread within organizations participating in the above noted programs
CALCULATION
Number of potential criteria attainable by Pay For Results, Behavioural
Supports Ontario, Access To Care, and Partnering For Quality
DATA SOURCE
Data requested from each of the Project Leads by the Team Lead, Performance
Improvement
EXCLUSION/INCLUSION
CRITERIA
Includes:
1. Criteria as above for each of the 4 organizations for a total of 24 for
the denominator
TIMING/FREQUENCY OF
RELEASE
How often, and when, are data
being released
Reported: Data updated upon request
E.g. Be as specific as
possible…..data are released
annually in mid-May
South West LHIN Balanced Scorecard Technical Specifications
43
LEVELS OF COMPARABILITY
TRENDING
Years available for trending
LIMITATIONS
Specific limitations
ADDITIONAL INFORMATION
COMMENTS
Additional information regarding the
calculation, interpretation, data
source, etc.
REFERENCES
Provide URLs of any key references
E.g. Diabetes in Canada, HTTP://....
RESPONSIBILITY FOR
REPORTING
DATE CREATED (YYYY-MM-DD)
2014-03-14
DATE LAST REVIEWED (YYYYMM-DD)
2014-03-14
South West LHIN Balanced Scorecard Technical Specifications
44