About Toronto Grace Health Centre
Accreditation & Hospital Report

Accreditation

The Canadian Council on Health Services Accreditation (CCHSA) is a national accrediting body for health services in a Canada. Accreditation is used for health service organizations to evaluate and improve the quality of their services and is based on a national standard. Toronto Grace underwent an accreditation in 2006.

Results

Hospital Report

The Hospital Report series is an ongoing project to assess hospital performance in Ontario. It is a joint initiative of the Ontario Hospital Association and the Ministry of Health. The key objective for this report is to assist hospitals to identify strengths and opportunities for improvement. The scorecard report is organized using four domains or quadrants. The four quadrants need to be considered to provide an accurate picture of performance.

The following chart explains the various quadrants and how they are measured:

Quadrant	Area of Measurement	Source of Information
System Integration and Change	Support for quality improvement, integration of systems and process. Includes client centred care, information technology and staff skills.	Survey completed Dec. 2006
Clinical Utilization and Outcomes	Clinical processes and outcomes, looking at change in physical functioning, cognitive and psychosocial functioning, continence, care complexity and medication use.	Minimum Data Set (MDS) collected and submitted to the government April 2005- March 2006
Patient & Family Satisfaction	How patients and families perceive the care and their satisfaction with different aspects of care	NRC Picker Survey Fall 2006* *We did not participate in this survey and thus do not have any comparative results for this quadrant
Financial Performance	Efficiency, productivity and financial sustainability.	Data collected and submitted to government April 2005 March 2006

Indicators are used to evaluate performance and are measured in two ways. The first is a numeric value is given for each indicator. For many indicators, a higher number demonstrates a better the performance however, for some a lower score is preferred.

The second is a comparison of Complex Continuing Care facilities across the province. A target threshold is determined which represents the provincial averages.

Overall Results for Toronto Grace Health Centre 2006

The Hospital Report shows Toronto Grace to be a solid performer with some excellent clinical and organizational strengths. 23 indicators were measured and our overall performance is as follows:

14 indicators met the target threshold
5 indicators were above the target threshold
0 indicator was below the target threshold
4 indicators were not compared against the target threshold but the numeric values for each of the indicators were consistent with the provincial mean

Results by Quadrant

Systems Integration and Change

This quadrant measures efforts made by Ontario hospitals to improve linkages with other providers of care, to improve coordination of care and to invest in better information for decision making.

Seven indicators were measured in this quadrant:

Client centred care
Evidence based practice
Healthy work environment
Integration of care
Use of Information Technology
Use of RAI-MDS in quality improvement and clinical utilization management
Use of staff skills and competencies specific to Complex Continuing Care

Toronto Grace met the target threshold for all 7 indicators in this quadrant.

Clinical Utilization and Outcomes

Of the 13 indicators measured in this quadrant, Toronto Grace has met the target threshold in more than half of the indicators and has exceeded performance in 5 (38%) of all the indicators measured. This demonstrates that Toronto Grace continues excellence in patient care. The indicators that exceeded the provincial average are:

patients who are prescribed antipsychotic medications but with no psychiatric diagnosis
patients with communication decline
patients with increased depression/anxiety
patients with indwelling catheters
presence of pressure ulcers

The indicators that met the target threshold are:

patients with a decline in mobility
patients who improve in their ADL performance
patient falls
new stage 2 ulcers
use of physical restraints
decrease in bladder continence
patients with disruptive/severe pain

One indicator was not reported due to sample size short stay patients with acute pain.

Patient & Family Satisfaction

The Senior Management Team decided not to participate in 2006/2007 NRC Pickar Survey given that we had just completed the Accreditation process and a number of initiatives were identified from that review. In addition it was felt that since the Slow Stream Rehab program was in its early stages any data collected at that point would be unreliable.

Financial Performance

Consistent with past reports, our total and direct costs per Complex Continuing Care weighted patient day were significantly below the provincial average, a strong indication of our efficient financial performance. Our results with the other indicators in the quadrant were in line with expectations and exemplify our solid financial situation.