Balanced Scorecard & Patient Safety Indicators
Introduction – Three dimensions & nine strategic goals
Welcome to Sunnybrook’s Strategic Balanced Scorecard. The purpose of this report is to give you a window on the hospital to see how we are doing in meeting our nine strategic goals that were established in our 2015-18 Strategic Plan. Each of our nine strategic goals has a number of objectives and indicators, and in this report you will be able to see how Sunnybrook is performing in the dimensions of: quality of patient care, research and education, and sustainability and accountability.
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June 2018
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Our Strategic Balanced Scorecard provides an unprecedented level of transparency for our communities. We believe it is important for the many communities we serve across the province to see how we are meeting their needs to deliver excellent care, conduct innovative research, and offer rewarding educational experiences. We are providing this information in an easy to understand format with written explanations.
Since we are reporting on Sunnybrook’s goals & objectives, not all of this information is directly comparable with what other hospitals have chosen to report on their balanced scorecards. We plan to update this information twice a year and you should generally expect to see gradual advancement towards our targets. One of the challenges in any reporting tool is interpreting the information provided. It is important for you to realize that any single data point may not indicate that we have either achieved our target on a sustainable basis, or that there is a significant concern. We have therefore developed a unique color coded legend to indicate both point-in-time results as well as trends.
If you have any questions, please email: questions@sunnybrook.ca.
Quality of Care Goals
- Goal 1 - Objective 1.1.X:
Improve the patient experience and outcomes through inter-professional, high quality care - Goal 2 - Objective 1.2.X:
Focus on the highest levels of specialized care in support of our Academic Health Sciences Centre definition - Goal 3 - Objective 1.3.X:
Work with system partners and government to build an integrated delivery system in support of our communities and our Academic Health Sciences Centre definition - Goal 4 - Objective 1.4.X:
Achieving excellence in clinical care associated with our strategic priorities
Objective 1.1.1
Reduce preventable harm
How do we measure this?
Critical events related to the escalation of care (#)
This indicator measures the number of escalation of care-related safety incidents resulting in major/critical harm to the patient. Escalation of care is the communication process that occurs once clinical deterioration is recognized by any clinical member of the team. The overarching goal of this metric is to permanently eliminate preventable harm related to escalation of care.
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Equal or Better Than Target
Worse Than Baseline
Moving Toward Target
Baseline
Moving Away From Target
In DevelopmentObjective 1.1.2
Lead provincially in patient outcomes for select QBPs
How do we measure this?
Stroke: 30 day in-hospital mortality (Rate)
Quality Based Procedures (QBPs) are an integral part of Ontario's Health System Funding Reform (HSFR). This indicator measures the number of deaths from all causes occurring in-hospital within 30 days of first admission for patients with a diagnosis of Stroke.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
This indicator excludes any Alternate Level of Care days.
Comments
While the stroke mortality rate increased this reporting cycle, the rate for all of calendar year 2017 was 7.5%, an improvement over both 2015 and 2016. In addition, Sunnybrook has been consistently lower than the provincial average of 10.8%*. Of note, the distribution of stroke patients discharged from Sunnybrook has shifted since the baseline year (2012-13), with fewer transient ischemic attack (TIA) patients being admitted, who are generally less severe. The target for this indicator was based on performance in 2012-13, and aimed for improvement over 3 years. This was considered a stretch goal, as the hospital was already a strong performer compared to the Provincial average. Mortality cases continue to be reviewed in detail as part of the stroke Morbidity and Mortality (M&M) rounds. *Source: Ontario and Local Health Integration Network 2016/17 Stroke Report Cards and Progress Reports (age and sex adjusted)
COPD: 30 day in-hospital mortality (Rate)
Quality Based Procedures (QBPs) are an integral part of Ontario's Health System Funding Reform (HSFR). This indicator measures the number of deaths from all causes occurring in-hospital within 30 days of first admission for patients with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD).
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
This indicator excludes any Alternate Level of Care days.
Objective 1.1.3
Lead in the provision of high quality end of life care
How do we measure this?
Palliative care ALC length of stay (Days)
This indicator reflects the average length of stay (LOS) for Alternate Level of Care (ALC) patients in acute care that are waiting for a palliative care bed. Improvement in this area will enable Sunnybrook to achieve a greater number of timely transfers of palliative patients to the right setting (better quality).
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
This indicator excludes long stay patients > 10 days.
Satisfaction with End of Life Care (as reported by family) (%)
Sunnybrook’s vision for quality dying is that “Dying patients and their families receive the highest quality of care”. This indicator reveals the percent of respondents who replied positively to the following question: "Overall, how would you rate the care that your family member received in the time leading up to their death at Sunnybrook?".
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentObjective 1.2.1
To increase the proportion of specialized activity
How do we measure this?
Specialized care - Tertiary/Quaternary clinical activity (%)
A traditional measure of “specialized care” has been to look at the amount of Tertiary/Quaternary activity vs. Primary/Secondary level activity. The Ministry of Health and Long Term Care (MOHLTC) has established an algorithm for the assignment of cases into four levels of care. Sunnybrook applies further refinement to this categorization based on the Clinical Activity Allocation Model (CAAM) per the 2015-18 Strategic Plan.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentObjective 1.3.1
To identify, develop and establish internal and external clinical partnerships that enhance safe transitions of care to the community, timely access to high quality care and efficient use of resources
How do we measure this?
COPD: Readmissions within 30-Days of discharge (Rate)
This indicator reflects all-cause unplanned 30-day readmission rates for patients with a principal discharge diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Unplanned readmissions to acute care facilities following discharge are tracked to monitor the quality of care provided
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentCHF: Readmissions within 30-Days of discharge (Rate)
This indicator reflects all-cause unplanned 30-day readmission rates for patients with a principal discharge diagnosis of Congestive Heart Failure (CHF). Unplanned readmissions to acute care facilities following discharge are tracked to monitor the quality of care provided.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmenteDischarge Summary Completion within 48 hours (%)
Immediately following discharge from the hospital is a time of high risk for the patient. Providing timely, accurate and complete information to the patient's primary care provider can reduce the risks to the patient including medication errors and re-admission. This indicator measures the percentage of eDischarge summaries completed and signed-off within 48 hours of discharge from an acute admission.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentObjective 1.4.1
To achieve the highest level of clinical outcomes and standards in Cancer
How do we measure this?
Breast: Radiation ready to treat to treatment wait time (%)
This indicator measures the percentage of breast cancer patients who are seen for radiation treatment within target (1, 7, 14 days, depending on priority) after they are ready to be treated.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentComments
While recorded wait times increased, patient care was not compromised and those ready for treatment were treated. In July 2016, the start of the current indicator cycle, only 52% of patients were seen for radiation within the target number of days. This was due in part to service interruptions from mandatory upgrades for 3 days in all radiation units. All other months reached between 74-90% within target, averaging out to 81.9%. In consultation with the program, one potential area for improvement lies in strengthening our processes regarding data capture. The entry of Ready to Treat (RTT) dates by staff is manual, and as of October, a new Quality Assurance process was implemented to review and correct RTT dates as patients start their treatment course.
Prostate: Radiation referral to consult wait time (%)
This indicator measures the percentage of prostate cancer patients seen within the provincial wait time target of 14 days, and reflects the time between a patient’s referral to a radiation oncologist and the actual visit with the oncologist.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentColorectal: Surgical decision to treat to treatment wait time (%)
This indicator demonstrates the percentage of patients treated for Colorectal cancer within the provincial wait time target for all priority categories (i.e. urgent, semi-urgent, elective). It identifies the wait time from when a patient and surgeon decide to proceed with surgery, until when the actual procedure is completed.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentObjective 1.4.2
To achieve the highest level of clinical outcomes and standards in Heart and Vascular
How do we measure this?
Heart: EVAR Mortality (Rate)
This indicator reflects the risk-adjusted intra and post-operative mortality rate within 30 days of patients undergoing elective and emergency endovascular repair of an abdominal aortic aneurysm. The current benchmark is typically what is achieved when hospitals participate in the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP).
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentObjective 1.4.3
To achieve the highest level of clinical outcomes and standards in Image-Guided Brain Therapies.
How do we measure this?
Stroke: Readmissions within 30-Days of discharge (Rate)
This indicator encompasses all-cause unplanned 30-day readmission rates for patients with a principal discharge diagnosis of Stroke. Unplanned readmissions to acute care facilities following discharge are tracked to monitor the quality of care provided.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentObjective 1.4.4
To achieve the highest level of clinical outcomes and standards in High Risk Maternal and Newborns
How do we measure this?
Newborns: Necrotizing Enterocolitis (Rate)
Necrotizing Enterocolitis (NEC) is a potentially fatal gastrointestinal disease that primarily affects premature infants. This indicator reflects the rates of Necrotizing Enterocolitis in the neonatal ICU for babies < 33 weeks.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentObjective 1.4.5
To achieve the highest level of clinical outcomes and standards in Trauma
How do we measure this?
Trauma: ISS >= 16 mortality (Rate)
Treatment of severely injured patients with an Injury Severity Score (ISS) >= 16 is very challenging. This indicator reflects in-hospital mortality for patients, age >= 16 with an ISS >= 16 (the latter excludes patients with severe burns and those without vital signs).
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentBurns: Mortality for burns over 20% of total body surface area (Rate)
While large burns can be fatal, advances in burn care developed by Sunnybrook experts over the last two decades have helped to reduce mortality. This indicator measures the mortality rate of patients with burns over 20% of their body surface area; the latter excludes patients deemed non-survivable upon admission.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentResearch & Education Goals
- Goal 5 - Objective 2.5.X:
Change health care practice through the creation, translation and application of new knowledge with a focus on our Strategic Priorities. - Goal 6 - Objective 2.6.X:
Lead in the development of innovative methods of teaching and learning
Objective 2.5.1
To create new knowledge that advances our strategic priority areas.
How do we measure this?
Total External Funding ($ million)
This indicator highlights the success of all Sunnybrook Research Institute (SRI) scientists in attracting research funding from external sources (i.e. private sector, granting bodies, grants from charitable organizations).
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentTotal External Funding in Strategic Priorities (%)
This indicator highlights how much external funding received by SRI is attributable to research in a Strategic Priority.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
The Strategic Priority breakdown for External Funding is as follows: 39% = Cancer 17% = Heart & Vascular 35% = Image-Guided Brain Therapies 7% = Trauma & Burns 2% = High Risk Maternal & Newborn
Publications (#)
This indicator shows the success of SRI scientists in publishing their research in peer-reviewed journals.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentPublications in Strategic Priorities (%)
This indicator demonstrates how far SRI-authored papers are concentrated in Strategic Priority areas. It is noteworthy that many papers not attributed to any Strategic Priority area may be in an area of basic science that as yet is not targeted within a Strategic Priority.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
The Strategic Priority breakdown for Publications is as follows:: 41% = Cancer 10% = Heart & Vascular 24% = Image-Guided Brain Therapies 15% = Trauma & Burns 9% = High Risk Maternal & Newborn
Cumulative Citations (% Increased based on 5 year rolling period)
Citations are a measure of the dissemination impact of published papers. This indicator tracks Cumulative Citations of all SRI publications over a rolling 5 year period to measure the impact over time of SRI-based research.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentObjective 2.5.2
To test and translate new knowledge into improved treatment approaches and apply in the clinical domain
How do we measure this?
Preclinical Activity (# protocols)
This indicator shows the number of active preclinical research protocols at SRI.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentPreclinical Activity in Strategic Priorities (%)
This indicator reflects the proportion of preclinical activity attributable to Strategic Priority areas.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
The Strategic Priority breakdown for Preclinical Activity is as follows: 44% = Cancer 9% = Heart & Vascular 41% = Image-Guided Brain Therapies 6% = Trauma & Burns 0% = High Risk Maternal & Newborn
Human Protocols Activity (# protocols)
This indicator shows how many clinical research protocols are active, and illustrates the progression of SRI's clinical research studies towards achieving a clinical application.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentHuman Protocols Activity in Strategic Priorities (%)
This indicator demonstrates how many clinical research protocols are attributable to a Strategic Priority, and illustrates the progression of SRI's clinical research studies towards achieving a clinical application.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
The Strategic Priority breakdown for Human Protocols Activity is as follows: 51% = Cancer 13% = Heart & Vascular 12% = Image-Guided Brain Therapies 15% = Trauma & Burns 10% = High Risk Maternal & Newborn
First-in-Human Studies Activity (# studies)
This indicator shows the number of active clinical research trials that are the first to include human subjects, and thus shows SRI's innovation in clinical research activities.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFirst-in-Human Studies Activity in Strategic Priorities (%)
This indicator shows how the active clinical research trials that are the first to include human subjects are attributable to a Strategic Priority, and thus shows SRI's innovation in clinical research activities.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
The Strategic Priority breakdown for First-in-Human Studies Activity is as follows: 63% = Cancer 7% = Heart & Vascular 23% = Image-Guided Brain Therapies 7% = Trauma & Burns 0% = High Risk Maternal & Newborn
Objective 2.5.3
To support the commercialization of technologies into industry.
How do we measure this?
Private Sector Partnership Funding ($ million)
Private sector involvement in SRI research provides an industry-institute partnership through which business growth can be coupled with advancing the development of discoveries made by SRI scientists. This indicator shows how much funding Private Sector Partnerships have contributed to SRI research.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentPrivate Sector Partnership Funding in Strategic Priorities (%)
Private sector involvement in SRI research provides an industry-institute partnership through which business growth can be coupled with advancing the development of discoveries made by SRI scientists. This indicator demonstrates how Private Sector Partnership contributions align with Strategic Priority areas.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
There are 235 Private Sector Partnerships actively contributing funds to SRI researchers, 57% of which are partnerships in a Strategic Priority area as follows: 49% = Cancer 20% = Heart & Vascular 25% = Image-Guided Brain Therapies 4% = Trauma & Burns 2% = High Risk Maternal & Newborn
IP Disclosures (#)
An Intellectual Property (IP) disclosure indicates the development of a new device or drug that is sufficiently advanced for commercialization activities to be initiated. This indicator shows the number of new research disclosures arising from SRI-based research.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
Eighty six percent (86%) of SRI's IP Disclosures are in a Strategic Priority area as follows: 53% = Cancer 13% = Heart & Vascular 22% = Image-Guided Brain Therapies 13% = Trauma & Burns 0% = High Risk Maternal & Newborn
Licenses (#)
A license agreement grants the right to use intellectual property for a defined period, allowing the holder to bring the specified technology to market. This indicator shows the number of newly signed licenses to access SRI intellectual property.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
Eighty three percent (83%) of SRI's Licenses are in a Strategic Priority area as follows: 60% = Cancer 40% = Heart & Vascular 0% = Image-Guided Brain Therapies 0% = Trauma & Burns 0% = High Risk Maternal & Newborn
Start-Ups (#)
This indicator shows the number of newly incorporated start-up companies based on technology/intellectual property developed in SRI laboratories.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
Zero percent (0%) of SRI's Start-Ups are in a Strategic Priority area: 0% = Cancer 0% = Heart & Vascular 0% = Image-Guided Brain Therapies 0% = Trauma & Burns 0% = High Risk Maternal & Newborn
Comments
Over the past decade Sunnybrook Research Institute (SRI) has initiated 14 start-ups, and 3 additional start-ups have arisen from the latter. The ambitious target of a new start-up per year was intended to maintain this level of activity; however, due to issues around timing, target was not achieved this past year. We nonetheless intend that it will be achieved next year.
Objective 2.5.4
To support the implementation of discoveries and/or findings into practice
How do we measure this?
Implementation Partnerships (#)
This indicator shows the number of active Health Canada-approved multi-centre studies that are led by Sunnybrook, and also highlights Sunnybrook's leadership in translating research towards improving healthcare practice.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentImplementation Partnerships in Strategic Priorities (%)
This indicator shows the proportion of active Health Canada-approved multi-centre studies that are attributable to Strategic Priority areas, and also highlights Sunnybrook's leadership in translating research towards improving healthcare practice.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
The Strategic Priority breakdown for Implementation Partnerships is as follows: 0% = Cancer 0% = Heart & Vascular 100% = Image-Guided Brain Therapies 0% = Trauma & Burns 0% = High Risk Maternal & Newborn
Objective 2.5.5
To support the wide-spread adoption of discoveries and/or findings into practice
How do we measure this?
Widespread adoption as evidenced by: # of Evidence-based guidelines (where applicable)
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentWidespread adoption as evidenced by: Government remuneration (where applicable)
Sunnybrook Health Sciences Centre (SHSC) / Sunnybrook Research Institute (SRI) made application to the Ontario Health Technology Advisory Committee (OHTAC) in mid-December 2013 toward uptake of Magnetic Resonance (MR) guided high-intensity focused ultrasound (HIFU) for ablation of uterine fibroids into the Ontario health care system. The process to date has included: (i) internal presentation to OHTAC at the end of February 2014 (ii) broad-based clinical assessment in comparison to current standard of care (iii) epidemiological assessment, notably safety and outcomes analyses (iv) economic analysis (v) internal OHTAC review culminating in a “public consultation” process through posting its findings. The recommendation was posted in March 2015: “… that MR-guided high-intensity focused ultrasound be considered as one option in the treatment of symptomatic uterine fibroids in women who are unresponsive to medical therapy”.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentObjective 2.6.1
Enhance utilization of technology enabled learning (e.g. LMS, simulation) throughout Sunnybrook
How do we measure this?
Simulation encounters of non-Sunnybrook staff learners (#)
This indicator measures the total number of simulation encounters of external (non-Sunnybrook staff) learners (e.g. Medical Students, Residents and Fellows).
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentSimulation encounters of Sunnybrook staff learners (#)
This indicator measures the total number of simulation encounters of internal (Sunnybrook staff) learners (e.g. Registered Nurses, Physicians and Health Disciplines).
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
This indicator's target has been re-balanced to better reflect the expected distribution of simulation activity through the course of the year.
Courses completed by Sunnybrook Staff on the LMS (#)
Sunnybrook's Learning Management System (LMS) is a versatile, personalized and online system that has become the tool for managing educational activities and keeping users connected to the learning community within Sunnybrook. The LMS provides tools to create eLearning (authored) courses. It also ‘hosts' the courses, and provides a searchable ‘catalogue' for finding and selecting courses. The indicator below reflects the number of online courses completed by Sunnybrook Staff on the Learning Management System.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
This indicator accounts for only clinical courses completed through Sunnybrook's Learning Management System (LMS) and excludes nursing corporate re-certification and Sunnycare.
Objective 2.6.2
Enhance health literacy skills of Sunnybrook providers to better engage patients and families
How do we measure this?
Learners who have been trained on health literacy principles (#)
Health Literacy Workshops continue to be offered across the organization with the aim of building capacity for effective teaching competencies in the area of patient and family education. Health literacy is of continued and increasing concern for health professionals, as it is a primary factor behind health disparities. The indicator that follows reflects the number of physicians, student learners and staff that attended a health literacy workshop and were trained on health literacy principles.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
Target reflects an annual increase
Patients and families who have been served at a learning centre (#)
As part of Sunnybrook's overarching education strategy, the Hospital has developed a multi-faceted family and patient education strategy. With regard to the latter, Sunnybrook has launched patient and family education (PFE) learning centres in the Odette Cancer Centre, Holland Orthopaedic Centre, and Women’s and Babies' Program. This indicator highlights the number of patients, family members and caregivers that have been served at one of these learning centres.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
Target reflects an annual increase
Funded PFE documents produced using the PFE toolkit (#)
Patient and Family Education (PFE) is one of the key areas under the Education portfolio at Sunnybrook. The PFE vision at Sunnybrook is to reinvent patient and family education. To help meet this objective, the PFE committee has created a toolkit for Sunnybrook staff to guide in the development of print resources. This indicator measures the number of funded Patient Family Education (PFE) documents produced using the PFE toolkit.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentSustainability & Accountability Goals
- Goal 7 - Objective 3.7.X:
Advance our Strategic Priorities through the appropriate and purposeful use of resources - Goal 8 - Objective 3.8.X:
Deliver sustainable performance that meets health systems expectations and commitments - Goal 9 - Objective 3.9.X:
Create a culture of engagement, respect and inclusiveness that attracts and inspires talent to achieve excellence
Objective 3.7.1
Position our Strategic Priorities for ongoing development to invent and deliver world class care
How do we measure this?
Strategic Priority Investment Funding ($)
This indicator serves to identify at least $250,000 of focused Strategic Priority investment in each year of the strategic plan.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentObjective 3.7.2
Align Medical Human Resource Plan (MHRP) to our Strategic Priorities
How do we measure this?
Strategic Priority Investment in Medical HR
This indicator measures the percentage of Medical Human Resource positions hired to the 5 Strategic Priority programs.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
The FY 2017-2018 result is comprised of 30 new hires, of which 17 (56.7%) are contributing to the five (5) Strategic Priorities as follows: 30% = Cancer (9 hires) 7% = Trauma & Burns (2 hires) 7% = High Risk Maternal & Newborn (2 hires) 7% = Heart & Vascular (2 hires) 7% = Image-Guided Brain Therapies (2 hires)
Objective 3.8.1
Ensure patients have access to specialized services when they need them
How do we measure this?
High Risk Birth Cases (#)
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
Timeline has been updated to reflect Fiscal Year.
Open to Trauma (%)
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentTAVI Procedures (#)
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
The targets for these indicators are revised annually, pending receipt of funding letters from the TCLHIN.
MitraClip Procedures (#)
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
The targets for these indicators are revised annually, pending receipt of funding letters from the TCLHIN.
Objective 3.8.2
Optimize capacity by ensuring patients are cared for in the right place
How do we measure this?
Corporate Acute Care Occupancy (%)
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentComments
Hospital occupancy has been above 95% target for the last two years. While overall the average length of stay has improved, increases in the number of inpatients and Emergency Department visits have contributed to increased demands on hospital services. In addition, since April, 2017, Sunnybrook has been providing care to many more patients identified as Alternate Level of Care (ALC) which indicates that they do not need acute care services. Many of these patients have very long lengths of stay as they wait for post-acute services to become available. During this time period, despite high occupancy, the hospital was able to reduce the total number of OR cancellations due to a lack of available beds compared to FY 2015-16. The Occupancy Executive Committee (OEC) continues to create new occupancy improvement initiatives and regularly reviews performance.
Objective 3.8.3
Provide evidence-based care within the defined funding envelope
How do we measure this?
Eligible Quality Based Procedure (QBP) cases meeting expected length of stay targets (%)
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentFootnotes
The following QBPs are reflected in this indicator: Hemorrhagic Stroke, Hip Fracture, Ischemic Stroke, Transient Ischemic Attack (TIA), Unilateral Hip Replacement and Unilateral Knee Replacement.
Objective 3.9.1
To attract and retain talent
How do we measure this?
Staff Turnover (%)
Staff Turnover is a provincial indicator that is measured at all hospitals in Ontario, and is well aligned with staff engagement. The target is the Ontario Hospital Association benchmark.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentLeadership promotion from within Sunnybrook (%) - Directors
Sunnybrook has a Strategic Workforce Plan and we need to measure how we are investing in our Directors. This indicator is an important reflection of the effectiveness of our talent leadership program.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentLeadership promotion from within Sunnybrook (%) - Managers
Sunnybrook has a Strategic Workforce Plan and we need to measure how we are investing in our Managers. This indicator is an important reflection of the effectiveness of our talent leadership program.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentLeadership promotion from within Sunnybrook (%) - Program Chiefs
Sunnybrook has a Strategic Workforce Plan and we need to measure how we are investing in our Program Chiefs. This indicator is an important reflection of the effectiveness of our talent leadership program.
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Equal or Better Than TargetWorse Than BaselineMoving Toward TargetBaselineMoving Away From TargetIn DevelopmentObjective 3.9.2
To build leadership capacity
How do we measure this?
New leadership learning development programs delivered to leaders (#)
Sunnybrook is committed to investing in building our leadership capacity by providing teaching and learning opportunities for our leaders of today, and our emerging leaders of tomorrow. Through Sunnybrook’s Leadership Institute we will provide emerging leaders, developing leaders and advanced leaders with educational programs and courses that build upon their leadership competencies and improve their ability to be the best leaders they can be.
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- Nosocomial Antibiotic Resistant Organism...
- Clostridium Difficile
- Central Line Infection
- Hand Hygiene 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 required to publicly report. We encourage you to review our results through the tabs above, as well as visit our online Strategic Balanced Scorecard within the parent tabs in order to gain a comprehensive understanding of our nine strategic goals, the various objectives and targets we have established, and our performance in achieving these.
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. Clostridium difficile is a bacterium that causes diarrhea and other intestinal conditions. See Clostridium difficile tab for additional detail.
Ministry Reporting Requirements for VRE & MRSA Bacteremia:
Our quarterly results for the period Q3 2018/2019 by site are as follows:
| VRE | MRSA | |||
|---|---|---|---|---|
| Campus | Cases* | Rate | Cases* | Rate |
| Bayview | 0 | 0.00 | 1 | 0.02 |
| Holland Centre | 0 | 0.00 | 0 | 0.00 |
| St. John's Rehab | 0 | 0.00 | 0 | 0.00 |
*New nosocomial
Need more information?
Need more Information? You can also read our questions & answers about these bacteria.
Monthly Clostridium Difficile Rates
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.
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
| Feb-18 | Mar-18 | Apr-18 | May-18 | Jun-18 | Jul-18 | Aug-18 | Sep-18 | Oct-18 | Nov-18 | Dec-18 | Jan-19 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Nosocomial Cases | 10 | 8 | 2 | 6 | 6 | 1 | 5 | 9 | 6 | 7 | 5 | 8 |
 Rate/1000 Patient Days – Nosocomial | 0.48 | 0.35 | 0.09 | 0.26 | 0.27 | 0.04 | 0.22 | 0.41 | 0.26 | 0.32 | 0.23 | 0.37 |
 Rate/1000 Patient Days – Admitted | 0.34 | 0.26 | 0.14 | 0.22 | 0.14 | 0.04 | 0.27 | 0.18 | 0.3 | 0.23 | 0.09 | 0.09 |
Clostridium Difficile - Bayview Site
| Feb-18 | Mar-18 | Apr-18 | May-18 | Jun-18 | Jul-18 | Aug-18 | Sep-18 | Oct-18 | Nov-18 | Dec-18 | Jan-19 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Nosocomial Cases | 10 | 7 | 2 | 5 | 6 | 1 | 5 | 9 | 6 | 7 | 5 | 8 |
| Rate/1000 Patient Days – Nosocomial | 0.69 | 0.44 | 0.13 | 0.32 | 0.4 | 0.06 | 0.32 | 0.59 | 0.38 | 0.49 | 0.33 | 0.52 |
| Rate/1000 Patient Days – Admitted | 0.48 | 0.38 | 0.2 | 0.32 | 0.2 | 0.06 | 0.39 | 0.26 | 0.38 | 0.33 | 0.13 | 0.13 |
Clostridium Difficile - Holland Centre Site
| Feb-18 | Mar-18 | Apr-18 | May-18 | Jun-18 | Jul-18 | Aug-18 | Sep-18 | Oct-18 | Nov-18 | Dec-18 | Jan-19 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Nosocomial Cases | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Rate/1000 Patient Days – Nosocomial | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Rate/1000 Patient Days – Admitted | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
Clostridium Difficile - St. John's Rehab Site
| Feb-18 | Mar-18 | Apr-18 | May-18 | Jun-18 | Jul-18 | Aug-18 | Sep-18 | Oct-18 | Nov-18 | Dec-18 | Jan-19 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Nosocomial Cases | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Rate/1000 Patient Days – Nosocomial | 0 | 0 | 0 | 0.19 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Rate/1000 Patient Days – Admitted | 0 | 0.46 | 0.46 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
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 |
Q4 (17/18) | Q1 (18/19) | Q2 (18/19) | Q3 (18/19) |
|---|---|---|---|---|
| Incidents | 2 | 2 | 4 | 0 |
| Days | 4315 | 4264 | 4054 | 3971 |
| Rate/1000 central line days | 0.46 | 0.47 | 0.99 | 0.00 |
 With Ross Tilley Burn Centre Patients |
Q4 (17/18) | Q1 (18/19) | Q2 (18/19) | Q3 (18/19) |
|---|---|---|---|---|
| Incidents | 2 | 2 | 4 | 0 |
| Days | 4760 | 4761 | 4468 | 4341 |
| Rate/1000 central line days | 0.42 | 0.42 | 0.90 | 0.00 |
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 Hygiene Compliance - All Sites - January 2018 to March 2018
| Moment 1 |
Bayview | Holland Centre | St. John's Rehab |
|---|---|---|---|
| % Compliance | 72.52 | 70.09 | 86.78 |
| Moment 4 |
Bayview | Holland Centre | St. John's Rehab |
|---|---|---|---|
| % Compliance | 88.58 | 89.60 | 90.06 |
| 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)
The Hospital Standardized Mortality Ratio (HSMR) is a measurement that compares a hospital’s mortality rate with the overall national average rate. While this indicator provides a measure of overall mortality, it should be considered alongside other indicators when assessing the quality of care provided.
A ratio that is greater than the annual national average suggests that the hospital’s mortality rate is higher than the average rate. A ratio that is below the annual national average suggests that the hospital’s mortality rate is lower than the average rate.
How do we measure this?
Results 2012-2017
Legend
Moving towards the national average Better than the national average | HSMR | 2013-2014 | 2014-2015 | 2015-2016 | 2016-2017 | 2017-2018 |
|---|---|---|---|---|---|
| Indicator results | 92 | 86 | 84 | 77 | 73 |
| National average* | 95 | 94 | 93 | 91 | 91 |
*Excluding Quebec.
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
| Bayview Site |
Q4 (17/18) | Q1 (18/19) | Q2 (18/19) | Q3 (18/19) |
|---|---|---|---|---|
| Percentage | 99.9 | 100.0 | 100.0 | 100.0 |
| Holland Site |
Q4 (17/18) | Q1 (18/19) | Q2 (18/19) | Q3 (18/19) |
|---|---|---|---|---|
| Percentage | 100.0 | 100.0 | 100.0 | 100.0 |
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?
Timely Administration Rate of Prophylactic Antibiotics - All Sites
| Hips |
Q4 (17/18) | Q1 (18/19) | Q2 (18/19) | Q3 (18/19) |
|---|---|---|---|---|
| Within time frame | 67 | 50 | 65 | 87 |
| Total cases | 58 | 50 | 65 | 87 |
| Percentage | 98.53 | 100.0 | 100.0 | 100.0 |
| Knees |
Q4 (17/18) | Q1 (18/19) | Q2 (18/19) | Q3 (18/19) |
|---|---|---|---|---|
| Within time frame | 271 | 253 | 268 | 296 |
| Total cases | 274 | 262 | 270 | 304 |
| Percentage | 98.9 | 96.6 | 99.3 | 97.4 |
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 |
Q4 (17/18) | Q1 (18/19) | Q2 (18/19) | Q3 (18/19) |
|---|---|---|---|---|
| Incidents | 8 | 8 | 10 | 13 |
| Days | 3602 | 3275 | 3175 | 2902 |
| Rate/1000 ventilator days | 2.22 | 2.44 | 3.15 | 4.48 |
| With Ross Tilley Burn Centre Patients |
Q4 (17/18) | Q1 (18/19) | Q2 (18/19) | Q3 (18/19) |
|---|---|---|---|---|
| Incidents | 10 | 9 | 12 | 14 |
| Days | 3895 | 3572 | 3358 | 3026 |
| Rate/1000 ventilator days | 2.57 | 2.52 | 3.57 | 4.63 |
