Welcome to our Strategic Balanced Scorecard. This tool provides an electronic window into our hospital to show you how we're meeting our eight strategic goals, established in our 2006 Strategic Plan.
To view these goals, click through the tabs above or take a look at the strategic model by clicking the icon below. You may also view our performance regarding the various objectives and indicators for each of our goals.
This scorecard provides an unprecedented level of transparency and allows us the opportunity to show the communities we serve across the province how we are meeting their needs to deliver excellent care, conduct innovative research, and offer rewarding educational experiences.
To assist you in interpreting the information we're reporting, we've developed a unique, colour-coded legend to indicate both point-in-time result as well as trends. For indicators with a (red) current status, you can view our action plans by clicking on the red indicator column in the specified chart.
Please keep in mind that since we're reporting on our own hospital's goals and objectives, all the information we've provided is not directly comparable with what other hospitals may choose to report on their own balanced scorecards.
We thank you for taking the time to visit our scorecard. If you have any questions, please email questions@sunnybrook.ca
Quality of patient care goals:
- Lead in innovative care experiences that improve outcomes for our patient populations:
Objective 1.1 – 1.2 - Lead in safety best practices:
Objective 2.1 – 2.3 - Lead provincially and nationally in managing the care of critically ill patients:
Objective 3.1 - 3.3
Objective 1.1
To improve patient satisfaction
Patient satisfaction is a well established measure of quality of care and supporting families during the course of care has the capacity to make breakthrough change in patient outcomes.
How do we measure this?
Patient Satisfaction – Overall Care Received (% Positive Score)
* Targets are based on Ontario Teaching Hospital average.
Objective 1.2
To maximize the number of acute care patients receiving appropriate Venous Thromboembolism (VTE) Prevention medications.
Almost all patients who are hospitalized are at risk of developing deep venous thrombosis or pulmonary embolism. These conditions can be serious and lead to prolonged hospitalization, need for additional therapy, long term complications, or even death. Appropriate prevention of VTE is an important way to minimize these complications of hospitalization and includes a risk assessment for each patient, provision of anticoagulant medications, and monitoring for the development of symptoms of VTE.
How do we measure this?
Percent of Patients Receiving Appropriate Thromboprophylaxis
Objective 2.1
To decrease nosocomial antibiotic resistant organism infection rates (Clostridium difficile, Vancomycin-Resistant Enterococci, Methicillin-Resistant Staphylococcus aureus)
Clostridium difficile is a bacterium that causes diarrhea and other intestinal conditions. The use of antibiotics increases the chances of developing C. difficile associated disease (CDAD). The combination of the presence of C. difficile and the number of people receiving antibiotics can lead to outbreaks of CDAD in hospitals. Staphylococcus aureus is a bacterium that is normally found on the skin and the nose. Methicillin-resistant Staphylococcus aureus (MRSA) is resistant to antibiotics commonly used to treat S. aureus. MRSA can be transmitted and cause outbreaks in hospitals. Enterococci are bacteria that are commonly found in the bowel. Vancomycin-resistant Enterococci (VRE) are resistant to the antibiotic vancomycin. VRE can be transmitted and cause outbreaks in hospitals.
The following charts represent monthly rates (per 1000 patient days) where patients have developed the above infections. The blue bars represent rates of infection that were acquired during the patient's hospital stay in Sunnybrook - also known as a nosocomial infection. The green bars represent rates of infections that are acquired in another health care setting or in the community - this is categorized as an 'admitted' infection in the graph. The red line represents the Canadian Nosocomial Infection Surveillance Program (CNISP) hospital acquired (nosocomial) rate used as a benchmark for each organism.
How do we measure this?
Clostridium difficile – All sites
The Canadian Nosocomial Infection Surveillance Program (CNISP) Benchmark for nosocomial Clostridium difficile has been updated to ≤ 0.54 per 1,000 patient days from ≤ 0.64 per 1,000 patient days as of November 2011.
Methicillin-Resistant Staphylococcus aureus – All sites
The Canadian Nosocomial Infection Surveillance Program (CNISP) Benchmark for nosocomial Methicillin-resistant Staphylococcus aureus has been updated to ≤ 0.59 per 1,000 patient days from ≤ 0.81 per 1,000 patient days as of January 2012.
Vancomycin-Resistant Enterococci – All sites
The Canadian Nosocomial Infection Surveillance Program (CNISP) Benchmark for nosocomial Vancomycin Resistant Enterococci has been updated to ≤ 0.70 per 1,000 patient days from ≤ 0.15 per 1,000 patient days as of November 2011.
Clostridium difficile – Bayview site
The Canadian Nosocomial Infection Surveillance Program (CNISP) Benchmark for nosocomial Clostridium difficile has been updated to ≤ 0.54 per 1,000 patient days from ≤ 0.64 per 1,000 patient days as of November 2011.
Methicillin-Resistant Staphylococcus aureus – Bayview site
The Canadian Nosocomial Infection Surveillance Program (CNISP) Benchmark for nosocomial Methicillin-resistant Staphylococcus aureus has been updated to ≤ 0.59 per 1,000 patient days from ≤ 0.81 per 1,000 patient days as of January 2012.
Vancomycin-Resistant Enterococci – Bayview site
The Canadian Nosocomial Infection Surveillance Program (CNISP) Benchmark for nosocomial Vancomycin Resistant Enterococci has been updated to ≤ 0.70 per 1,000 patient days from ≤ 0.15 per 1,000 patient days as of November 2011.
Clostridium difficile – Holland Centre site
The Canadian Nosocomial Infection Surveillance Program (CNISP) Benchmark for nosocomial Clostridium difficile has been updated to ≤ 0.54 per 1,000 patient days from ≤ 0.64 per 1,000 patient days as of November 2011.
Methicillin-Resistant Staphylococcus aureus – Holland Centre site
The Canadian Nosocomial Infection Surveillance Program (CNISP) Benchmark for nosocomial Methicillin-resistant Staphylococcus aureus has been updated to ≤ 0.59 per 1,000 patient days from ≤ 0.81 per 1,000 patient days as of January 2012.
Vancomycin-Resistant Enterococci – Holland Centre site
The Canadian Nosocomial Infection Surveillance Program (CNISP) Benchmark for nosocomial Vancomycin Resistant Enterococci has been updated to ≤ 0.70 per 1,000 patient days from ≤ 0.15 per 1,000 patient days as of November 2011.
Objective 2.2.1
To decrease surgical site infection rates (Coronary Artery Bypass Graft)
Reducing infection risks and preventing infections related to surgery improves outcomes for cardiac surgery patients. Sunnybrook will focus on decreasing the rate of deep sternal surgical site infections to international benchmarks, or better, for all coronary artery bypass graft surgery patients admitted to Sunnybrook. National Healthcare Safety Network (NHSN) benchmarks are used as reference for the respective targets. Cardiac surgeries are monitored for infections up to 1 year post surgery. Therefore the rates displayed are preliminary and may change in subsequent reports. It should be noted that the calculation of infection rates reflects low denominator values; a small change in the number of infections significantly impacts the overall rate.
How do we measure this?
Deep sternal infection rate - Coronary Artery Bypass Graft (CABG) surgery
*Previous report and current cycle: Cardiac surgeries are monitored for infections up to 1 year post surgery. Therefore the rates displayed are preliminary and may change in subsequent reports.
Objective 2.2.2
To decrease surgical site infection rates (Hips/Knees)
Reducing infection risks and preventing infections related to surgery improves outcomes for hip and knee surgery patients. Sunnybrook will focus on decreasing the rate of surgical site infections to international benchmarks, or better, for all hip and knee surgery patients admitted to Sunnybrook. National Healthcare Safety Network (NHSN) benchmarks are used as reference for the respective targets. Hip and knee surgeries are monitored for infections up to 1 year post surgery. Therefore the rates displayed are preliminary and may change in subsequent reports. It should be noted that the calculation of infection rates reflects low denominator values; a small change in the number of infections significantly impacts the overall rate.
How do we measure this?
1. Surgical infection rate - Hip
*Previous report and current cycle: Hip and knee surgeries are monitored for infections up to 1 year post surgery. Therefore the rates displayed are preliminary and may change in subsequent reports.
2. Surgical infection rate - Knee
*Previous report and current cycle: Hip and knee surgeries are monitored for infections up to 1 year post surgery. Therefore the rates displayed are preliminary and may change in subsequent reports.
Objective 2.2.3
To decrease surgical site infection rates (Caesarean Sections)
Reducing infections related to caesarean sections improves outcomes for obstetrical patients and their babies. Sunnybrook will focus on decreasing the rate of surgical site infections to the international standard, or better, for all caesarean section patients admitted to Sunnybrook. National Healthcare Safety Network (NHSN) benchmarks are used as reference for the respective targets. It should be noted that the calculation of infection rates reflects low denominator values; a small change in the number of infections significantly impacts the overall rate.
How do we measure this?
Caesarean section surgical site infection rate
*Target: 2009-10 NHSN Target applied.
Objective 2.2.4
To decrease surgical site infection rates (Colorectal/Hepatobiliary and Pancreatic Cancer)
Reducing infection risks and preventing infections related to surgery improves outcomes colorectal, hepatobiliary and pancreatic cancer patients. Sunnybrook will focus on decreasing the rate of surgical site infections to international benchmarks, or better, for all colorectal, hepatobiliary and pancreatic cancer patients admitted to Sunnybrook. National Healthcare Safety Network (NHSN) benchmarks are used as reference for the respective targets. It should be noted that the calculation of infection rates reflects low denominator values; a small change in the number of infections significantly impacts the overall rate.
How do we measure this?
1. Colorectal cancer surgical infection rate
2. Hepatobiliary and pancreatic cancer surgical infection rate
* Cancer surgeries are monitored for infections up to 1 month post surgery followed by clinical committee review and approval. Therefore the rates displayed are preliminary and may change in subsequent reports.
Objective 2.3
To prevent intra-operative adverse events and surgical complications through the implementation of the Surgical Safety Checklist on all surgical procedures, as recommended by the World Health Organization.
It has been proven that the use of a surgical checklist helps to reduce the rates of death and major complications after surgery. By using a surgical checklist, the surgical team is able to confirm important information about the patient and to ensure that the necessary steps have been taken prior and will be taken during the procedure to ensure safe patient care. This indicator refers to the percentage of surgeries in which a three-phase surgical safety checklist was performed.
How do we measure this?
The percentage of surgeries in which a surgical safety checklist was performed
Objective 3.1
To improve outcomes for STEMI (ST Elevation Myocardial Infarction) patients requiring emergent Percutaneous Coronary Intervention (PCI) through a collaborative partnership between the Emergency Department, Schulich Heart Program and Toronto ambulance services.
Clinical evidence has shown that a contact to balloon (PCI) time of 90 minutes or less results in the best patient outcomes. Sunnybrook will focus on improving outcomes for heart attack patients who require emergency PCI by achieving the standard of practice of 90 minutes or less for contact to PCI time through improved communication and enhanced processes between the Emergency Department, Schulich Heart Program and Toronto ambulance services. As part of this innovative program ambulance patients may by-pass the hospital in their respective catchment area, or stop briefly at their catchment hospital prior to being transferred directly to Sunnybrook's STEMI program; contact to balloon time ambulance patients are therefore impacted by factors external to Sunnybrook.
How do we measure this?
By-pass Ambulance Patients: Percent of patients with contact to balloon time less than 90min
*Target: Targets are based on an absolute 10% improvement from FY 10/11 performance.
Transferred Ambulance Patients: Percent of patients with contact to balloon time less than 120min
*Target: Targets are based on an absolute 10% improvement from FY 10/11 performance.
Sunnybrook Walk-In Patients: Percent of patients with contact to balloon time less than 90min
*Target: Targets are based on an absolute 10% improvement from FY 10/11 performance.
Objective 3.2
To improve outcomes for stroke patients requiring emergent thrombolytic therapy through a collaborative partnership between the Emergency Department and Brain Sciences Program
Clinical evidence has shown that a door to needle (tPA) time of 60 minutes or less results in the best patient outcomes. Sunnybrook will focus on improving outcomes for stroke patients who require emergency tPA by achieving the standard of practice of 60 minutes or less for door to needle time through improved communication and enhanced processes between the Emergency Department and Brain Sciences Program.
How do we measure this?
Percent of patients with mean door to needle time less than 60min
Note: The target is currently under development.
Objective 3.3
To improve access to tertiary care for high risk mothers
Improving access to specialized services for high risk mothers improves outcomes for both mothers and their babies. Sunnybrook will focus on improving access to care for high risk mothers by striving to remain open to critical transfers 100% of the time.
How do we measure this?
Percentage of hours available for CritiCall transfers
Research & education goals:
- Lead in the creation, translation and application of knowledge into clinical best practice:
Objective 4.1 – 4.2 - Focus our strategic programs to ensure the development of strategic priorities that are recognized globally:
Objective 5.1
- Lead nationally in the education of healthcare professionals:
Objective 6.1
Objective 4.1
To increase the development of new knowledge by Sunnybrook Research Institute (SRI)
The upward progress of our research enterprise is measured by a number of indicators that track research achievements on an annual basis and over many years, and trends in those indicators guide annual investments in SRI. Total extramural funding measures success by our researchers in obtaining peer reviewed grants; the proportion of publications on which the first or last author is an SRI scientist indicates the share of research output in a leadership role; the proportion of "high impact" publications is a measure of the quality of publications*.
How do we measure this?
1. Total extramural funding
* “High impact” is defined by an impact factor based on the top 5% of journals listed by the Institute for Scientific Information (ISI)
** Baseline: Baseline calculated post-Women’s College demerger.
*** Previous Report: Includes transient (2010-2013) funding for CFI Research Hospital Fund project
2. Proportion of peer reviewed publications that are first/last authored
* “High impact” is defined by an impact factor based on the top 5% of journals listed by the Institute for Scientific Information (ISI)
** Baseline: Baseline calculated post-Women’s College demerger.
*** Previous Report: Includes transient (2010-2013) funding for CFI Research Hospital Fund project
3. Proportion of all peer reviewed publications that are first/last authored in high-impact journals
* “High impact” is defined by an impact factor based on the top 5% of journals listed by the Institute for Scientific Information (ISI)
** Baseline: Baseline calculated post-Women’s College demerger.
*** Previous Report: Includes transient (2010-2013) funding for CFI Research Hospital Fund project
Objective 4.2
To increase the impact of new knowledge by Sunnybrook Research Institute (SRI)
External citations are an established indicator of knowledge transfer within the research community. Sunnybrook will focus on creating a positive impact on the creation, translation and application of knowledge from basic science through to clinical best practice amongst our research peers, as indicated by the number of citations to knowledge created at Sunnybrook Research Institute.
How do we measure this?
1. Proportion of citations where SRI scientist is first or last author
* Baseline: Baseline calculated post-Women’s College demerger.
2. Proportion of citations that are SRI first/last authored, and in high-impact journals
* Baseline: Baseline calculated post-Women’s College demerger.
Objective 5.1
To concentrate program research activity into Sunnybrook's Strategic Priorities (SPs)
Strategic Priorities (SPs) are Sunnybrook's areas of excellence as defined through internationally accepted criteria for research, university defined criteria in teaching, and excellence in clinical care. Concentrating our research activity into these SPs will allow Sunnybrook to achieve its vision to invent the future of healthcare.
How do we measure this?
1. Percentage funding attributed to SP(s)
* Baseline calculated post-Women’s College demerger.
2. Percentage first/last authored publications attributed to SP(s)
* Baseline calculated post-Women’s College demerger.
3. Percentage first/last authored related citations attributed to SP(s)
* Baseline calculated post-Women’s College demerger.
4. Percent first/last authored high impact publications attributed to SP(s)
* Baseline calculated post-Women’s College demerger.
** The target relates only to the share of publications attributed to the SP, and not of all publications.
5. Percentage first/last authored related citations attributed to SP(s) in high impact journals
* Baseline calculated post-Women’s College demerger.
** The target relates only to the share of publications attributed to the SP, and not of all publications.
Objective 6.1
To be a recognized leader in the education of medical trainees among our peer adult teaching hospitals in Toronto
High ranking on the University of Toronto Medical School Rotation Effectiveness Scores (RES) relative to our University of Toronto affiliated peers (adult teaching hospitals) is a proxy of national leadership in the area of medical education. Sunnybrook will focus on achieving #1 or #2 ranking in our departmental areas in comparison with our peers.
No. of depts/divisions ranked 1 or 2 relative to peer teaching hospitals UofT Med School Rotation Effectiveness Scores
Sustainability & accountability goals:
- Lead in performance measurement and management, including financial management and wait times.
Objective 7.1 – 7.4 - Become the healthcare workplace of choice
Objective 8.1 – 8.2
Objective 7.1
To achieve or exceed Hospital Accountability Agreement (HAA) volumes
Meeting volume targets indicates Sunnybrook's ability to deliver on our accountability to government and to the people of Ontario in the services we deliver.
How do we measure this?
1. Acute Inpatient and Day Surgery - total weighted units
*Current Cycle: Preliminary forecast based on YTD August 2011 results
2. Complex Continuing Care - weighted patient days
3. Mental Health - total number of patient days
4. Long Term Care - total number of patient days
5. Inpatient rehabilitation - total number of patient days
6. Total number of emergency visits
7. Total number of ambulatory care visits
* Performance and Target for 11/12 Q2 reflect a change in Ministry reporting guidelines, resulting in a decrease of approximately 100,000 annual visits compared to the prior year.
Objective 7.2
To achieve sustainable financial health by achieving total margin target as defined through the Hospital Accountability Agreement
Total margin is simply total revenue minus total expense. Zero or a positive number indicates that we are managing within our available resources.
How do we measure this?
Total margin budget variance
Objective 7.3
To manage the effective use of our beds by monitoring length of stay against targets.
Length of stay (in days) for typical patients is a measure of efficiency in the use of limited hospital resources and can have an impact on access to hospital inpatient services. Sunnybrook has set a target of meeting or exceeding Ontario hospital best quartile length of stay for typical patients. The following indicators compare the actual average length of stay by quarter for all patients against the target length of stay for that program's patient population. Note: Target Length of Stay is calculated against Actual Length of Stay from the Current Cycle time period. Therefore, targets vary each time period.
How do we measure this?
1. Odette Cancer Program
2. Veterans and Community Program
3. Trauma, Emergency and Critical Care Program
4. Musculoskeletal Program – Holland Centre
5. Musculoskeletal Program – Bayview Campus
6. Women's and Babies Program
7. Schulich Heart Program
Objective 7.4
To achieve wait times volumes as agreed to through the Hospital Accountability Agreement (HAA)
The Government of Ontario has developed a wait times strategy to reduce waiting times for key procedures. Additional funding has been provided to increase patient care activity related to the specific procedures (i.e., hip/knee replacements, cancer surgery, magnetic resonance imaging, computerized tomography scans). Sunnybrook has committed to help reduce these wait times by performing this additional patient activity.
How do we measure this?
1. Hip/Knee replacement surgeries – base + incremental cases
2. Cancer surgeries – base + incremental cases
*Current Cycle: Based on YTD August 2011 results
3. MRI - base + incremental cases
4. CT - base + incremental cases
Objective 8.1
To ensure Sunnybrook maintains high levels of excellence in factors related to retention of staff
A high retention rate is an indicator of a preferred work environment as compared to peers and creates a stable professional environment for our staff and patients. Targets are updated annually in October in relation to peer hospital rates.
How do we measure this?
1. Absenteeism Rate (days/year)
2. Staff Turnover Rate
3. Nursing FTE Fill Rate
Objective 8.2
To ensure hospital staff are engaged and believe that Sunnybrook is the workplace of choice
Improvement within key domains in our Staff Engagement Survey indicates we are moving toward our goal of being the workplace of choice.
How do we measure this?
Percentage of overall staff score for the Staff Engagement Survey (high category)
* Indicator revised due to change in Staff Engagement Survey.
**The Target represents the Canadian norm score for staff who rate Engagement as "Favourable" (the highest ranking category).
- Introduction
- Nosocomial Antibiotic Resistant Organism...
- Central Line Infection
- Hand Hygience Compliance
- Hospital Standardized Mortality Ratio
- Surgical Safety Checklist Compliance
- Surgical Site Infection Prevention
- Ventilator Associated Pneumonia
Publicly Reported Safety Indicators
The Ontario Ministry of Health and Long Term Care has established a number of safety indicators that all hospitals are equired to publicly report. One of Sunnybrook’s eight strategic goals is to “Lead in safety best practice”, and as such, we are thrilled to be a part of this Ministry initiative. We have fully integrated the publicly reported safety indicators into our Strategic Balanced Scorecard under the “Quality of Patient Care” dimension, where you will also find many other safety indicators.
We encourage you to visit our complete online Strategic Balanced Scorecard within the parent tabs above in order to gain a comprehensive understanding of our eight strategic goals, the various objectives and targets we have established, and our performance in achieving these.
However, if you only wish to view the Ministry mandated indicators at this time, you can access these directly through the following tabs. MRSA and VRE also cause types of infection other than bacteremia. Sunnybrook has chosen to closely monitor and publicly report all MRSA and VRE infections.
Nosocomial Antibiotic Resistant Organism Infection Rates
MRSA and VRE are important nosocomial pathogens which can cause a variety of types of infection in hospitalized patients. Bacteremias are infections where the bacteria are present in the patient's blood, and represent the most serious type of infection caused by MRSA and VRE. MRSA and VRE bacteremias provide one measure of patient safety and quality of care and should prompt hospitals to look carefully at infection prevention and control practices.
Ministry Reporting Requirements for VRE & MRSA Bacteremia:
Our quarterly results for the period Jan - March 2013 by site are as follows:
| VRE | MRSA | |||
| Campus | Cases* | Rate | Cases* | Rate |
| Bayview | 0 | 0.00 | 0 | 0.00 |
| Holland | 0 | 0.00 | 0 | 0.00 |
*New nosocomial
Need more information?
For more indepth metrics and trending on, Clostridium difficile (C diff), Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant Enterococci (VRE), please Quality and patient safety tab 2.1 above. You can also Read our Questions & Answers about these bacteria
Central Line Infection (CLI)
Central lines or central venous catheters are inserted into large central veins in the neck, upper chest or groin. They are primarily used to deliver medication and fluid to patients. One of the complications that can result from a central line is that of infection which may result from the central line itself. A central line infection is the presence of bacteria or yeast in the blood of a patient that results when a central line is inserted.
The infection rate below reflects the rate of infections per quarter per 1000 central line days (1,000 central line days represents a comparator by which we can compare the total number of infections). Please note that although reporting is by site, all patients requiring a central line are cared for at the Bayview Sunnybrook site. The table below the graph shows the rate numerically as well as the actual number of incidents occurring in the quarter. The rates have been shown with and without the patients cared for in the Ross Tilley Burn Centre, because the risk of central line infection is not comparable for patients with extensive burns.
How do we measure this?
Central Line Infection (CLI) - Bayview Site
 Without Ross Tilley Burn Centre Patients |
Q1 (12/13) | Q2 (12/13) | Q3 (12/13) | Q4 (12/13) |
| Incidents |
2 | 8 | 4 | 3 |
| Days |
3396 | 3935 | 3968 | 4073 |
 With Ross Tilley Burn Centre Patients |
Q1 (12/13) | Q2 (12/13) | Q3 (12/13) | Q4 (12/13) |
| Incidents | 2 | 8 | 4 | 3 |
| Days | 3916 | 4361 | 4376 | 4403 |
Hand Hygiene
The single most common transmission of health care-associated infections (HAIs) in a health care setting is via hands of health care workers who have touched colonized or infected patients or contaminated material or equipment. Monitoring hand hygiene practices and the provision of timely feedback are vital to improving compliance and, in turn, reducing HAIs.
Consistent with the Ministry of Health's reporting requirements, the following graph show Sunnybrook's compliance rates with respect to proper hand hygiene compliance:
- Before initial patient/patient environment contact
- After patient/patient environment contact
How do we measure this?
Hand Hygience Compliance - All Sites - January to March 2013
| Moment 1 |
The % compliance for before initial patient/patient environment contact by combined categories of health care provider (HCP). Note: # times hand hygiene performed before initial pat/pat env contact divided by # observed hand hygiene indications for before initial pat/pat env contact. |
| Moment 4 |
The % compliance for after patient/patient environment contact by combined categories of HCP. Note: # times hand hygiene performed after pat/pat env contact divided by # observed hand hygiene indications for after pat/pat env contact. Multiply by 100. |
Hospital Standardized Mortality Ratio (HSMR)
Hospital Standardized Mortality Ratio (HSMR) is a measurement that compares a hospitals' mortality rate with the overall national average rate. It has been used by many hospitals worldwide to assess and analyze mortality rates. While the calculation provides an indication of expected deaths versus actual deaths, please avoid using HSMR as the sole indicator of the quality of patient care in any hospital.
A ratio that is equal to 100 suggests that there is no difference between the hospital's mortality rate and the average national rate. A ratio greater than 100 suggests that the hospital's mortality rate is higher than the average national rate. A ratio less than 100 suggests that hospital's mortality rate is lower than the average national rate. Sunnybrook uses many different indicators to measure and guide the improvement of the quality of care. It is important to look at a variety of factors to better understand the overall quality of care and how it can be continuously improved.
***Update*** Methodology Change:
Please note that as of February 2012, the methodology for measuring HSMR has changed as follows:
- The previous baseline used for calculation was full year, 2004-2005. The new baseline uses full year 2009-2010 (starting Feb 2012 Q1 and Q2 2011-2012)
- Quebec data is now included in the 2009-2010 baseline (it was previously excluded)
- The list of diagnosis groups included in the HSMR has been updated. There are now 72 diagnosis groups compared to 65 groups previously. This may cause a variance in numbers.
- The Charlson Index Score algorithm has also been updated; Codes that don't exists in ICD10 have been removed as well as certain type 3 diagnosis (ie. diabetes, cancer, asterisk codes) have been added to the algorithm.
- The definition of medical and surgical patient population has changed and is now based on CMG partition codes. This could also lead to a variance in numbers.
How do we measure this?
Results 2007-2012
* Significantly different from the fiscal year 2009-2010 baseline HSMR of 100.
Surgical Safety Checklist Compliance
It has been proven that the use of a surgical checklist helps to reduce the rates of death and major complications after surgery. By using a surgical checklist, the surgical team is able to confirm important information about the patient and to ensure that the necessary steps have been taken prior and will be taken during the procedure to ensure safe patient care.This indicator refers to the percentage of surgeries in which a three-phase surgical safety checklist was performed.
How do we measure this?
Surgical Site Checklist Compliance
Surgical Site Infection Prevention
Surgical site infections (SSI) are the second leading type of healthcare-associated infection. Timely administration of prophylactic antibiotics is a key infection prevention strategy for hip and knee replacement surgeries. The greatest benefits are seen when antibiotics are administered within 60 minutes prior to skin incision. The following data shows the percentage of times we were able to administer the appropriate antibiotic within the recommended timeframe.
How do we measure this?
Surgical Site Infection Prevention - All Sites
| Hips |
Q1 (12/13) | Q2 (12/13) | Q3 (12/13) | Q4 (12/13) |
| Within time frame |
165 | 151 | 178 | 158 |
| Total cases |
166 | 153 | 182 | 162 |
| Knees |
Q1 (12/13) | Q2 (12/13) | Q3 (12/13) | Q4 (12/13) |
| Within time frame |
296 | 258 | 257 | 336 |
| Total cases |
304 | 264 | 259 | 340 |
Ventilator Associated Pneumonia (VAP)
Ventilator Associated Pneumonia (VAP) is defined as a Pneumonia occurring in patients in the ICU requiring mechanical ventilation (a machine which delivers artificial respirations). VAP is a complication that can lead to poor health outcomes for patients.
The VAP rate below reflects the rate of infections per quarter per 1000 ventilator days (1,000 ventilator days represents a comparator by which we can compare the total number of infections). Please note that although reporting is by site, all ventilated patients are cared for at the Bayview Sunnybrook site. The table below the graph shows the rate numerically as well as the actual number of incidents occurring in the quarter. The rates have been shown with and without the patients cared for in the Ross Tilley Burn Centre, because burn patients often have smoke inhalation so their risk of VAP is not comparable to other ventilated patients.
How do we measure this?
Ventilator Associated Pneumonia (VAP) - Bayview Site
| Without Ross Tilley Burn Centre Patients |
Q1 (12/13) | Q2 (12/13) | Q3 (12/13) | Q4 (12/13) |
| Incidents |
3 | 12 | 14 | 9 |
| Days |
2658 | 3020 | 3196 | 3363 |
| With Ross Tilley Burn Centre Patients |
Q1 (12/13) | Q2 (12/13) | Q3 (12/13) | Q4 (12/13) |
| Incidents | 5 | 13 | 14 | 9 |
| Days | 2885 | 3272 | 3392 | 3596 |
