CMHA TORONTO QUALITY PERFORMANCE REPORT
Balanced Scorecard and Program Scorecard
Reporting Period: Q4- 2011-12
1
PURPOSE:
To provide the Board with the first report of our efforts in strategic planning using the Balanced Scorecard (BSC)
as a management tool.
RECOMMENDATIONS
That the Board receives the report for information and discusses the performance measures
REASONS FOR RECOMMENDATIONS
In March 2010 the Strategic Plan for 2010-2013 was approved by the Board with a stipulation that quantifiable performance
metrics were needed. The report includes both organizational and programs scorecards result for the new strategic plan.
Additional measures and data may be added to future reports as we improve collection processes and systems throughout
201/13. It is also important to note that the performance report and associate measures will mature and evolve over time.
Performance thresholds may also be adjusted to reflect agency priorities and new information.
REPORT ELEMENTS
The report shows results for 39 measures measured at the organizational level, some of which are reported annually, no
immediate data. This report also includes a program level scorecard with 25 measures.
MEASURE STATUS
The status of each measure is indicated in the attached scorecards as:
● Green – equal or better than target
● Yellow – moving towards target
● Blue – in development/on track
● Red – level is below target
The summary scorecard is followed by a shortfall analysis sheet. For each of these measures, we provide explanations of why the
shortfall occurred and descriptions of resolution strategies being employed to improve performance.
2
Legend
Color
Decision
Leadership Action
Green ▲
Yellow ►
Blue
►
Red
▼
n.a.
KPI
Q 1 = April - June
Equal or better than target
Moving towards target
In development/on track
Level is below target
Not tracked during this period
Key Performance Indicator
Q 2 = July - September
Reinforce
Stay the course
Continue monitoring
Improvement required
Maintain a close watch on this
Q 3 = October - December
Q 4 = January - March
Perspective
Goal
Objectives
Finance
Ensure sufficient resources to achieve the mission and strategic directions
#
Measure
Target
Q1
Q2
Q3
Q4
Continue prudent
fiscal management
1
+.7%
+.7%
+6
%
+.1
%
-2.3%
-5.2%
2.3
%
1.8
%
▼
$3.5
million
$3.2
million
3.3
m
3.3
m
▲
<.5%
2
Develop and
implementing a
new fundraising
strategy
% variance of net surplus vs budget
% variance of investment returns actual vs
budget
3
Amount of reserve funds
4
Written/revised fund raising strategy
completed
5
6
% of implemented recommendations in the
strategy
% net growth in supplementary fundraising
<2%
Minimum
$2
million
Status
(green,
yellow,
red)
KPI
▲
-
complet
ed
-
-
By March
31/2011
tbd
-
-
-
-
►
tbd
-
-
-
-
►
3
Comments
A positive number indicates
that we are managing with
our available resources
The global economy
negatively affected
investment returns for all
managed balanced funds.
Quarterly (Deferred to 2012/13
budget for board approval
Quarterly (Deferred to 2012/13
budget for board approval)
Perspective
Client and Community
Goal
Meet client/community needs and foster inclusion
Objectives
Continue advocacy
and system leadership
7
8
Promote mental health
& understanding of
mental illness
Implement diversity
and equity plan
9
10
11
12
13
Develop and embed
consumer
participation
strategies
Measure
Target
# of leaderships/policy activities involved in at the
provincial, national and LHIN levels
n.a.
# of clients that are involved in advocacy activities
n.a
# of mental health promotion, workshops, presentations
offered within the last year
% of staff trained in Applied Suicide Intervention Skills
Training (ASIST)
% of programs that completed the development of their
Diversity & Equity work-plans
14
15
% of programs that implemented their CPI work-plans
Q2
-
71
-
Q3
Q4
-
45
-
82
103
Comments
Reductions reflect
adjustment in priorities
►
This project is in its first
year of implementation
Annually reported
-
139
97
87
▲
33%
94.3%
95.5%
▲
-
100%
-
99.19
%
-
▼
100%
▲
100%
-
-
-
65%
-
-
-
90%
Annually reported
100%
-
-
-
-
-
-
-
Compl
eted
-
90.7
%
-
Year 3 indicator.
Annually reported and
only applies to direct
service teams
Annually reported
Completed
document
Written Consumer Bill of Rights
4
Year 1 target only. This
represents clinical
programs only
Annually reported
80%
90%
80%
16
Status
(green,
yellow,
red)
100
% of staff participated in workshops
% of programs that have implemented 50% or more of
their Diversity& Equity work-plans
% of programs that develop their 2nd diversity work plan
Q1
▲
▲
Perspective
Goal
Internal Processes
Develop and provide recovery based integrated services
Objective
#
Measure
Target
Continue service in
high need areas
aligned with our
core competence
17
% of functional centres that fall within the LHIN
corridor for number of clients served
100%
18
19
Develop chronic
disease prevention
and management
options
20
% of staff that received recovery training
21
% of clients satisfied with service received
22
% of clients surveyed for having a chronic disease
23
% of clients in EI and ACT who have been screened for
metabolic syndrome
% of staff that received training in chronic disease
management
# of clients receiving direct services that are involved in
prevention activities (footcare, walking group, SMW,
Chronic Disease Management (CDM) training, diabetes
screening)
% of clients screened with an approved instrument
24
25
Develop concurrent
disorder capacity
% of functional centres that fall within the LHIN
corridor for number of client visits
% of programs at 90% capacity
26
27
28
% of clients screened as having concurrent disorders
receiving integrated care
% of staff that received concurrent disorder training
Q1
Q2
Q3
Q4
-
100%
100%
81.8%
▼
-
100%
100%
100%
100%
100%
80%
90.7%
90.9%
83.3%
90.9%
▼
100%
-
-
100%
▲
KPI
-
87%
-
-
-
-
-
-
80%
-
72%
-
7%
-
80%
▲
-
-
▼
-
-
55%
-
-
-
-
80%
tbd
-
-
-
-
80%
-
88.7%
-
88.7
5
▲
KPI
80%
50%
50%
40%
Status
(green,
yellow,
red)
KPI
Comments
Two programs did not achieved
their target
All quarterly targets have been
achieved
10 of 11 programs met capacity
targets
Annually reported
Target has been exceeded
Delayed start due to other
training priorities.
Delayed program start due to
other organizational training
Year two indicator only.
Target already achieved (Year 1
indicator only)
To be determined
▲
Perspective
Learning and Growth
Goal
Develop a quality culture
Objective
#
Measure
Ensure that
CMHA remains a
great place to
work
29
% of staff satisfied in their current job
30
32
33
Develop a
Learning culture
Achieve
accreditation
Q1
Q2
Q3
Q4
-
87%
-
-
Status
(green,
yellow,
red)
KPI ▼
-
-
100%
100%
100%
▲
7
-
2.52
2.76
2.72
▲
-
100%
-
100%
▲
-
90%
90%
93%
▼
90%
31
Develop Quality
& Safety
Improvement
Target
% of exiting staff that voiced satisfaction/
dissatisfaction with the agency
# of paid sick days per staff
% of formal complaints resolved as per policy
timeline
n/a
% team conducting monthly safety huddles
100%
34
% of staff who received safety training
100%
35
# WSIB Claims
4
36
Balanced scorecard developed
37
▼
93.4%
93.4%
98%
-
4
0
1
-
-
-
-
# of successful student placement within the last year
Completed
document
7
-
9
9
8
▲
38
% of ROP compliance (24/26)
100%
82%
92%
92%
100%
39
QMENTUM certification – 24 months
n/a
-
-
-
Achieved
▲
KPI
▲
6
Comments
Annually reported
Based on recent
accreditation survey results
Results for satisfaction
only.
This applies to service
complaints only. Sixteen
( 16) compliments for staff
were formally received
Only one non-clinical
program has not reported
data.
4.6% increase over the last
period
Document completed
Target is on track as
projected
Accreditation status
achieved
Program Scorecard Q4,
(Jan – March 31, 2012)
Program Scorecard
January – March31, 2012
Color
Decision
Leadership Action
Green ▲
Yellow ►
Blue
►
Red
▼
n.a.
Program KPI (not included)
Q 1 = April - June
Equal or better than target
Moving towards target
In development/on track
Level is below target
Not tracked during this period
Key Performance Indicator
Q 2 = July - September
Reinforce
Stay the course
Continue monitoring
Improvement required
Maintain a close watch on this
Q 3 = October - December
KPI = Key Performance Indicator
Q 4 = January - March
Program
Key Measures
Baseline
Target
Q1
Results
Q2
Q3
ACTT
% of clients that have had
metabolic monitoring
within the last year
% of clients with no
mental health
hospitalization within the
last year (admissions
% of new clients receiving
n/a
65%
n/a
n/a
n/a
80%
Annually
n/a
75%
90%
84%
82%
79%
Quarterly
60%
100%
100%
100%
100%
Quarterly
Case
TE
Nil
7
Q4
Reporting Accreditation
Schedule Quality
Dimensions
Effectiveness
Accessibility
service within intake
benchmark
( separate targets for each
team based on model of
service)
% of clients participating
in meaningful activities
TW
CTO
MHJCM
MHJPP
60%
75%
80%
100%
94%
40%
98%
100%
89%
64%
100%
100%
88%
n/a
100%
40%
50%
n/a
63.5%
TE,TW,MHJCM,RAP
% of clients gainfully
employed
17.2%
25%
n/a
CTO
% of clients with no
mental health
hospitalizations within the
last year
87%
90%
Court
Support
% of clients that have
been diverted within the
last year
# of clients that were
successfully linked to
services
68%
Management
( TE-CM,TWCM,CTO,MHJPrevention,, RAP
TE,TW,MHJCM,RAP
TCM
TRHP
Intake &
40%
69%
60%
Quarterly
Quarterly
Quarterly
Accessibility
Accessibility
Accessibility
n/a
Semiannually
Client CentredServices
15.7%
n/a
Yr2
Effectiveness
92%
91%
89%
85%
Quarterly
Effectiveness
75%
n/a
n/a
n/a
77%
Annually
Effectiveness
61%
65%
n/a
n/a
n/a
71%
Annually
Continuity of
Services
5% increase in MCAS
Scores
53%
58%
n/a
100%
n/a
Semiannually
Safety
Reduction in the number
of admission
(hospitalization)
4 (clients)
3 (clients)
n/a
2
Clients
n/a
Semiannually
Safety
7% increase in client
satisfaction with program
activities
5% increase in MCAS
Scores
63%
70%
n/a
100%
n/a
Semiannually
Client-Centered
Services
53%
58%
n/a
90%
n/a
Semiannually
Safety
# of clients that were
successfully linked to
services
10% increase in file audit
61%
65%
n/a
n/a
n/a
Annually
Continuity of
Services
50%
60%
80%
80%
80%
Quarterly
Safety
8
100%
90%
n/a
100%
80%
Referral
Housing
SRC & What
Next
EI & TYP
SafeBed
Employment
each session
% of clients with 24mths
tenure
n/a
20% reduction in evictions
19 (#)
20% increase in the
number of participants
attending recovery based
education/groups
3% increase in the number
of clients in school,
working or volunteering
60% increase in the
number of clients who
receive first contact with
program within 72 hours
of referral
Decrease the turnaround
time for SB units
% of time that SB met the
4hrs
Increase the % of clients
that were successfully
linked to Case
Management Services
% of time that SB met the
72hrs target for referring
clients to Case
Management Services
8% increase in clients
accessing available
retention days past
probationary period
100% increase in youth
referral to employment
services
60%
80%
participation
rate
80%
75%
71%
73%
Quarterly
20%
67%
42%
21
Quarterly
80%
Participation
rate
82%
97.6%
100%
100%
Quarterly
Client-Centred
77%
80%
77%
90%
100%
100%
Quarterly
Accessibility
20%
80%
100%
100%
100%
100%
Quarterly
Accessibility
2 days
4hrs
1.24hr
1.24hr
1.65
2.11hr
Quarterly
Effectiveness
75%
85%
100%
100%
98.5
97%
Quarterly
Effectiveness
70%
80%
100%
95.6%
100
100%
Quarterly
Effectiveness
60%
75%
73%
71%
76%
84%
Quarterly
Effectiveness
67%
75%
73%
94%
85
Quarterly
Effectiveness
50%
100%
34%
100%
100
Quarterly
Effectiveness
9
Population Focus
SHORTFALL ANALYSIS – Organizational Scorecard
Shortfall Analysis Q4
Shortfall Analysis 1
Objective : Ensure sufficient resources to achieve the mission and strategic directions
Measure: # 2
Target:
% variance of investment returns actual
vs budget
Cause(s)
<2%
Resolution
Result:
-1.8 % ▼
▪ Investment returns for all managed balanced funds have been
negative due to slowdown in global economy and the Euro
debt crisis.




Investment manager has shifted asset mix away from European and
global markets
CMHA is tr
Transferring monthly dividends from the balanced fund to a money
market fund, thereby moving asset mix to more conservative position
Our investment policy has a medium to long-term timeframe. Although
these short-term losses are painful, long-term strategy for a balanced
portfolio should benefit over time.
10
Shortfall Analysis 2
Objective : Implement diversity and equity plan
Measure: # 12
Target:
% of staff who received safety training
Cause(s)
80%
65% ▼
▪
Fewer workshops offered and lower in staff participation
(workshops not filled to capacity as in previous years) because of
accreditation-related work-load in time of constraints
Resolution
Result:
 9-10 workshops will be offered in 2012-13 to ensure there is
enough space for staff to attend.
 Communication and coordination with managers to ensure each
training is filled to capacity will take place.
Shortfall Analysis 3
Objective :
Continue service in high need areas aligned with our core competence
Measure: # 17
Target:
Result:
% of functional centres that fall within the
LHIN corridor for number of clients served
Cause(s)
Resolution
81.8% ▼
100%
▪ ?
▪?
11
Shortfall Analysis 4
Objective : Continue service in high need areas aligned with our core competence
Measure: # 19
Target:
% of programs at 90% capacity
Cause(s)
100%
90.9 % ▼
▪ Staff transition into leadership positions, turnover and maternity
coverage. This required existing case managers to cover caseload until
new staff could be hired and trained
Resolution
Result:
 Review staff transition process…..
 Set monthly targets for new staff to increase staff caseloads to
meet/exceed program target of 90%
Shortfall Analysis 5
Objective : Develop chronic disease prevention and management options
Measure: # 24
Target:
% of staff that received training in
chronic disease management
50%
Result:
7% ▼
Cause(s)
▪ Delayed program start due to staffing & resource issues
Resolution
 Develop a revised implementation plan
 Secure funding from the LHIN
 Hire required staff
12
Shortfall Analysis 6
Objective : Ensure that CMHA remains a great place to work
Measure: # 29
Target:
Result:
% of staff satisfied in their current
job
Causes
90%
87%
Resolution
▼
▪ May be reflective of increase workload and increase stress
on the job as indicated in the accreditation work-life balance
survey. (N = 189 (down 5% from last year 2010).
▪ Wage restriction legislation
▪ Implementation of new MOHLTC initiatives
 HR committee to review results/root cause
 Continued dialogue with staff and managers
▪
Shortfall Analysis 7
Objective : Develop Quality & Safety Improvement
Measure: # 33
Target:
Result:
% team conducting monthly safety
huddles
100%
93%
▼
Cause(s)
▪ Non-clinical programs not actively reporting that they have
conducted safety huddles
Resolution
 Improve communication with non-clinical teams
 Create an e-reporting form.
13
Shortfall Analysis 8
Objective : Develop Quality & Safety Improvement
Measure: # 34
Target:
Result:
% of staff who received safety training
Cause(s)
100%
98% ▼
▪
Target has not been reached due to normal scheduling issues
 Develop alternative methods for training delivery
Resolution
Program Shortfall Analysis – Q4
Shortfall Analysis A
Program: CTO
Objective: To Increase Program Effectiveness
Measure:
Target:
% of clients with no mental health
hospitalizations within the last year
90%
Cause(s)
▪
Resolution
Result:
85% ▼

14
Shortfall Analysis B
Program: Housing
Measure:
Target:
% of clients with 24mths tenure
80%
73% ▼
60% of discharges for long term incarcerations, hospitalizations and
death
Cause(s)
Result:
Resolution
Shortfall Analysis C
Program: Housing
Measure:
Target:
20% reduction in evictions
15
21 ▼
52% for safety reasons and or long term incarcerations
Cause(s)
Resolution
Result:
Shortfall Analysis D
Program: CTO
Measure:
Target:
Result:
% of clients with no mental health
hospitalizations within the last year
87%
85% ▼
Cause(s)
Resolution
Definitions
15
Terms
Balanced Scorecard
Financial Perspective
Client/Community Perspective
Internal Process Perspective
Learning and Growth Perspective
Measure
Objective
Perspective
Target
Metabolic syndrome
KPI
Explanations
An integrated framework for describing strategy through the use of linked performance measures in four, balanced
perspectives ‐ Financial, Customer, Internal Process, and Employee Learning and Growth. The Balanced Scorecard acts
as a measurement system, strategic management system, and communication tool.
One of the four standard perspectives used with the Balanced Scorecard. Financial measures inform an organization
whether strategy execution, is leading to improved bottom line results.
One of the four standard perspectives used with the Balanced Scorecard. Measures are developed based on the answer
to two fundamental questions ‐ who are our target customers and what is our value proposition in serving them?
One of the four standard perspectives used with the Balanced Scorecard. Measures in this perspective are used to
monitor the effectiveness of key processes the organization must excel at in order to continue adding value for
stakeholders.
One of the four standard perspectives used with the Balanced Scorecard. Measures in this perspective are often
considered "enablers" of measures appearing in the other three perspectives.
A standard used to evaluate and communicate performance against expected results.
A concise statement describing the specific things an organization must do well in order to execute its strategy.
In Balanced Scorecard vernacular perspective refers to a category of performance measures
Represents the desired result of a performance measure.
Metabolic syndrome is the name for a group of risk factors linked to overweight and obesity that increase your chance for heart
disease and other health problems such as diabetes and stroke. The term “metabolic” refers to the biochemical processes involved in
the body's normal functioning. ...
www1.cardiotabs.com/glossary.asp
Key Performance Indicator
16