Executive Pay-For-Performance:
Organizational Measures of Performance
Heartland Regional Health Authority
July 11, 2012
Table of Contents
Organizational Performance Measures
Measure1.a.Attendance Management: Wage-Driven Premium…….…..3
Measure 1.b.Attendance Management: Sick Leave Hours …..…………4
Measure 1.c.Attendance Management: WCB Days….………………….5
Measure 2. Surgical Site Infection (SSI) Bundle ………………………..6
Measure 3.Infection Control ROP 1.3 …………………………………..7
Measure 4.Operating Results…………………………………………… 8
Patient/Client Experience Measures
Measure 1: Survey: Patient Satisfaction………………………………… 9
Behavioral Measures
Measure 1. Survey: Staff Satisfaction …………………………………. 10
Measure 2. Manager Competencies: 360 Degree Feedback Tool………11
Organizational Performance MeasuresMeasure 1.a. Attendance Management: Number Of Wage-Driven Premium Hours Per Full-Time Equivalent
Definition / A reduction in the total number of wage-driven premium (WDP) hours per full time equivalent (FTE) by union for a specific time period (e.g. month, quarter, fiscal year).
Baseline and Target / Baseline
- 35.18 wage-driven premium hours per FTE as of 2010-2011 actual baseline.
- 14.4% reduction to 28.6 wage-driven premium hours per FTE
Calculation or Methodology Description / The total number of wage-driven-premium hours divided by the total number of FTEs, for a specified time period.
Specifically, the numerator is the total number of wage-driven premium hours recorded in the SAHO payroll system for a specified time period. The denominator is the total number of full-time, part-time and casual FTEs for the same time period, calculated as the total number of paid hours recorded in the SAHO payroll system for Saskatchewan health sector employees for that time period divided by the average number of hours worked by a full time employee for that time period. This latter value varies due to the different number of days in a month but typically falls between 160 and 165 hours per month (the value is automatically calculated by the SAHO payroll system).
Data Sources / Wage-driven premium hours data - “Key Indicator Report”, SAHO Payroll Web Portal
FTEs – “Strategic Workforce Planning Report” (Paid FTE), SAHO Payroll Web Portal
Data Limitations
Frequency of Data Availability / Quarterly
Regional Health Authority Contact / Sheila Pajunen, VP of Human Resources
Measure 1.b. Attendance Management: Number Of Sick Leave Hours Per FTE
Definition / A reduction in the total number of work hours that employees are absent due to illness or injury per full time equivalent (FTE) by union for a specific time period (e.g. month, quarter, fiscal year).
Baseline and Target / Baseline
- 84.79 sick leave hours per FTE as of 2010-2011 actualbaseline.
- 5.5% reduction to 77.55 sick leave hours per FTE
Calculation or Methodology Description / The total number of work hours absent due to illness or injury divided by the total number of FTEs, for a specified time period.
Specifically, the numerator is the number of worked hours that employees are absent from the workplace due to illness or injury recorded as sick time in the SAHO payroll system for a specified time period. The denominator is the total number of full-time, part-time and casual FTEs for the same time period, calculated as the total number of paid hours recorded in the SAHO payroll system for Saskatchewan health sector employees for that time period divided by the average number of hours worked by a full time employee for that time period. This latter value varies due to the different number of days in a month but typically falls between 160 and 165 hours per month (the value is automatically calculated by the SAHO payroll system).
Data Sources / Sick leave hours data – “Key Indicator Report”, SAHO Payroll Web Portal
FTEs – “Strategic Workforce Planning Report” (Paid FTE), SAHO Payroll Web Portal
Data Limitations
Frequency of Data Availability / Quarterly
Regional Health Authority Contact / Sheila Pajunen, VP of Human Resources
Measure 1.c. Attendance Management: Number Of Lost-Time WCB Days Per 100 FTEs
Definition / A reduction in the number of lost-time Workers’ Compensation Board (WCB) days expressed as a rate per 100 full time equivalents (FTEs) for a specific time period (e.g. month, quarter, fiscal year).
Baseline and Target / Baseline
- 222.27 lost-time WCB days per 100 FTEs as of 2010-2011 actual baseline
- 14.1% reduction to 203.6 lost-time WCB days per 100 FTEs
Calculation or Methodology
Description / The number of lost-time WCB days divided by the total number of paid FTEs, expressed as a rate per 100 FTEs for a specified time period (e.g. fiscal year, quarter).
Specifically, the numerator is the total number of lost-time WCB days during a specified time period for all approved claims (after region formation) that were still active during that time period. The number of days included are both for the RHAs and their respective affiliates.
The denominator is the total number of full-time, part-time and casual FTEs for the same time period, calculated as the total number of paid hours recorded in the SAHO payroll system for Saskatchewan health sector employees for that time period divided by the average number of hours worked by a full time employee for that time period. This latter value varies due to the different number of days in a month but typically falls between 160 and 165 hours per month (the value is automatically calculated by the SAHO payroll system).
Data Sources / Saskatchewan Workers Compensation Board (WCB), August 2010
Data Limitations / Q4 data is not available as SK WCB is undergoing a data conversation process and data was not available for analysis.
Frequency of Data Availability / Quarterly
Regional Health Authority Contact / Sheila Pajunen, VP of Human Resources
Measure 2. Surgical Site Infection (SSI) Bundle
Definition / Level of achievement of implementation of all components of the SSI Bundle including all policies and procedures, education packages and capital equipment have been put in to place in each site performing surgeries by March 31, 2012.
The SSI Bundle focuses on four components of care:
1. Antimicrobial coverage perioperatively;
a. Appropriate use of prophylactic antibiotics
b. Antiseptic prophylaxis
2. Appropriate hair removal;
3. Maintenance of perioperative glucose control;
4. Perioperative normothermia.
SSI Bundle resources provided by Safer Healthcare Now!
Baseline and Target / Baseline
- No baseline available
- 2 sites have implemented the surgical site infection bundlein its entirety
Calculation or Methodology
Description / Total # of SSI Bundle Components implemented
Total # of Components
For each site performing surgery
Data Sources / HHR Implementation Audit
Data Limitations
Frequency of Data Availability / Quarterly
Regional Health Authority Contact / Gayle Riendeau, VP of Health Services
Measure 3. Establish Compliance With Infection Control ROP 1.3 (Reprocessing Of Endoscopes And Reusable Devices)
Definition / Achievement of implementing remediation strategies in areas deemed necessary for action as identified in the Board approved plan for ensuring that the organization is in compliance with relevant Canadian Standards Association (CSA) and Accreditation Standards for Reprocessing and Sterilization of Reusable Medical Device (ROP 12.22, CSA Standards).
Baseline and Target / Baseline
- 34 outstanding Process Standards and 8 outstanding Environment Standards as of March 31, 2011.
-There are a total of 97 standards in the R/S Standard document
-42 of the 97 standards (43%) were unmet at the start of this fiscal year. Five (5) standards are not applicable to HHR.
-Of the 42 standards, 34 standards can be classified as “process” and 8 standards can be classified as “environmental”.
-We will be measuring the compliance with the outstanding 42 standards by the end of the 2011-12 fiscal year.
Target
- To meet 100% of unmet Process Standards(34) and 50% of Environment Standards (4) by Mar 31, 2012
Calculation or Methodology Description / # of standards with a “met” compliance criteria
Total # of outstanding standards as of April 1/11
Indicator: Accreditation Canada’s (AC) evaluation (as having “met” or “not met” compliance criteria) for each of the Reprocessing and Sterilization of Reusable Devices Standards in the latest survey for which results are available.
Data Sources / “Met” compliance is based on evaluation of current practice against the standard’s test for compliance and was complete by the Infection Control Practitioner through a regional audit
Data Limitations / Formal survey visit/ review by Accreditation Canada have not occurred and are not scheduled until June 2013.
Frequency of Data Availability / Quarterly
Regional Health Authority Contact / Jeannie Munro, VP of Primary Health and Quality Services
Measure 4. Operating Results
Definition / Achievement of break-even or better on adjusted operating results as defined by the Ministry of Health’s reporting guidelines. Revenues equal to or in excess of expenditures once adjusted for transfers (i.e. Mortgage funding, Energy performance loan payments and Long term Care Reserves).
Baseline and Target / Baseline
- Break-even on 2011-12 adjusted operating results
- Adjusted operating results that are equal to or greater than 0.5% of 2011-12 total revenues
Calculation or Methodology
Description / Based on generally accepted accounting principles with adjustments outlined in the Ministry of Health’s Financial Reporting Guidelines
Data Sources / Audited financial statements
Data Limitations / Lag in audit process and/or financial statement preparation
Frequency of Data Availability / Annually
Regional Health Authority Contact / Stacey Bosch, VP of Corporate Services
Patient / Client Experience
Measure 1. Patient Satisfaction:HQC Survey question
Definition / This is a composite indicator made of 3 individual questions. Communication with nurses has been identified by patients to be an important aspect of hospital experience reflecting on the quality of the hospital care they received. This measure contributes to our understanding of our progress towards building a "smarter" health care system. Achievement of the percentage of "Always" responses among all respondents' answers to the three Nurse Communication questions to 84.85% by March 31, 2012.
"Always" responses among all respondents' answers to three Nurse Communication questions:
- During this hospital stay, how often did nurses treat you with courtesy and respect?
- During this hospital stay, how often did nurses listen carefully to you?
- During this hospital stay, how often did nurses explain things in a way you could understand?
Baseline and Target / Baseline
- 74.85%(Median)
- 84.85% of patients reporting that nurses “Always communicated well with them”
Calculation or Methodology
Description /
- The numerator is the number of times "always" was chosen as a response to any of the three questions.
- The denominator is the number of times any response was chosen for any of the three questions.
Data Sources / Health Quality Council, Patient Satisfaction Survey - Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.
Data Limitations / Lagging 3 month data. Data is not yet available for March 31, 2012. Results are the median from most current available monthly data (Feb 2012). Source: HQC Quality Insight Online.
Frequency of Data Availability / Quarterly/Monthly lagging data
Regional Health Authority Contact / Gayle Riendeau, VP of Health Services
Behavioural Competencies
Measure 1. Staff Satisfaction:Percentage Of Staff Responding To Worklife Pulse Survey Who Indicate That They Are Very Satisfied With Their Jobs
Definition / Level of achievement on % of staff choosing Favourable: which represents the respondents who chose "Very Satisfied/Satisfied" or "Strongly Agree/Agree" on job satisfaction based on results from Talent Map 2011 Employee Survey
Baseline and Target / Baseline
- 36.2% of staff responded they are very satisfied with their jobs
- 40.2% of staff respond they are very satisfied with their jobs
Calculation or Methodology Description / **Substituted Worklife Pulse Survey with Job Satisfaction "Favorable" results from Talent Map 2011 Survey, as HHR did not conducted Accreditation Worklife Pulse Survey during this time frame.
Data Sources / Talent Map 2011 Survey
Data Limitations / Different data sources
Frequency of Data Availability / Talent Map Survey was conducted in 2011
Regional Health Authority Contact / Sheila Pajunen, VP of Human Resources
Measure 2. 360 degree feedback based on Manager Competency Portfolio (MCP)
Definition / Vice Presidents - The Executive Leaders of Heartland Health Region have 9 of 11 Leadership Competencies related to managing self, managing your team, managing the work and managing collaboratively are identified as areas of strength defined through the HayGroup, 360 Degree Manager Competency Portfolio (MCP)
CEO – the HHR CEO’s performance was evaluated utilizing a CEO Performance Assessment Tool on 12 key areas relating to his position; Board of Directors, Strategic Planning, Operational Planning and Budgeting, Leadership, Organizational Structure, General Public, Ministry of Health, Communication, Participative Decision Making, Partnerships/Relationships, Trends in Health Care Management, Member Relations
Baseline and Target / Baseline
- n/a
- 9 of 11 Leadership Competencies related to managing self, managing your team, managing the work and managing collaboratively are identified as areas of strength
- the CEO of Heartland Health Region has 10 of 12 key areas related to his/her position identified as areas of performance fully achieved
Calculation or Methodology
Description / HayGroup MCP – VPs must acquire a score of 3 to have the competencies considered an area of strength
CEO Performance Assessment – CEO must acquire a score of 3 to have the areas considered fully achieved (rating categories (1) Does not meet, (2) Developing, (3) Fully Achieved, (4) Outstanding/Consistently Exceeds Requirements
Data Sources / HayGroup, 360 Degree Manager Competency Portfolio (MCP)
CEO was evaluated using a CEO Performance Assessment based on 12 key areas related to his position
Data Limitations / 2 different performance evaluation tools were used
Frequency of Data Availability / Yearly
Regional Health Authority Contact / Sheila Pajunen, VP of Human Resources
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July 11, 2012Heartland Health Region