Quality & Safety

Publicly Reported Indicators – Patient Safety

St. Mary’s is continually striving to achieve our Vision of Inspiring Excellence. Healthier Together. In addition to strategic goals and directions, we measure our performance in key patient safety indicators. The indicators found on this page are reported province-wide, which allows us to measure how we are doing in comparison to our results to provincial and national targets.

Using Performance Indicators 
These performance indicators are not meant to give medical advice or guarantee the Hospital’s services. Each indicator has an explanation about how it is measured and used and visitors are strongly encouraged to read this information.

Access To Care

Patient Safety

Hospital Standardized Mortality Ratio (HSMR)

Indicator Definition:

Hospital Standardized Mortality Ratio (HSMR)

The hospital standardized mortality ratio (HSMR) compares a hospital’s mortality (death) rate with the overall average rate. This important measurement provides the hospital with information that assists with identifying areas for improvement. When tracked over time, the HSMR indicates how successful the hospital is in reducing deaths and improving care.

The benchmark for HSMR is the National Average. In 2015/16, St. Mary’s had the lowest (best) HSMR in Canada, and in 2017/18 St. Mary’s had the eighth lowest score.

HSMR Calculation:

HSMR is calculated as a ratio of the actual number of deaths to the expected number of deaths among patients in acute care hospitals. This rate is then compared to the overall average rate for similar patients. An HSMR of 100 indicates that there is no difference between the hospital’s mortality rate and the overall average rate. Therefore, a value greater than 100 means that the hospital’s mortality rate is higher than the overall average rate and a value lower than 100 means the hospital’s mortality rate is lower than the overall average rate.

HSMR Annual Results

Year HSMR (SMGH rate) HSMR (national rate)
2020-21 (Feb YTD) 97 101
2019-20 87 95
2018-19 90 97
2017-18 84 100
2016-17 79 101
2015-16 76 103

Benchmark Source:
Canadian Institute Health Information (CIHI)

Surgical Safety Checklist

Case Definition:

The compliance measure refers to the percentage of surgeries in which a three phase surgical safety checklist was performed correctly and appropriately for each surgical patient. The SSCL is considered performed when the designated checklist coordinator confirms that surgical team members have implemented and/or
addressed all the necessary tasks and items in each of the three phases – ‘Briefing’, ‘Time-Out’ and ‘Debriefing’ – of the checklist based upon the Canadian Patient Safety Institute (CPSI)’s Surgical Safety Checklist.

The percent compliance with the surgical safety checklist is calculated as follows:

# of times all three phases of the checklist were performed/total surgeries x 100 = % compliance

2020 Compliance

Period Compliance
January – June 99.9
July-December 99.8

2019 Compliance

Period Compliance
January – June 99.8
July – December 99.9

2018 Compliance

Period Compliance
January – June 99.6
July – December 99.8

Surgical Safety Checklists

  • A surgical safety checklist is a one-page list of items that the surgical teams should dialogue about at one of the three key times; before the patient is given anesthesia will all team members present (briefing), before skin incision (time-out), and while all team members are present before closing the patient (debriefing).
  • Once implemented it can help improve overall efficiencies among surgical teams.
  • Research shows that using a surgical safety checklist can also lead to reduced surgical complications and mortality.

Infection Prevention and Control Reporting

Clostridium difficile Associated Disease (CDAD)

Indicator Definition:

C. difficile Nosocomial Rates per 1000 patient days

Incident rate of hospital-acquired infections for C. difficile (Clostridium difficile) per 1,000 days.

2021 Monthly Results

Month Cases Rate per 1,000 Patient Days
January < 5 0.39
February < 5 0.23
March 0 0

2020 Monthly Results

Month Cases Rate per 1,000 Patient Days
January < 5 0.18
February 0 0
March < 5 0.45
April 0 0
May < 5 0.24
June < 5 0.23
July < 5 0.62
August 0 0
September < 5 0.20
October < 5 0.19
November 0 0
December < 5 0.22

2019 Monthly Results

Month Cases Rate per 1,000 Patient Days
January 0 0.00
February < 5 0.22
March < 5 0.19
April 0 0.00
May 0 0.00
June < 5 0.20
July < 5 0.21
August < 5 0.45
September 0 0.00
October < 5 0.20
November 0 0.00
December < 5 0.42


2018 Monthly Results

Month Cases Rate per 1,000 Patient Days
January 0 0.00
February < 5 0.21
March < 5 0.40
April 0 0.00
May 0 0.00
June < 5 0.41
July 0 0.00
August 0 0.00
September 0 0.00
October < 5 0.20
November 0 0.00
December < 5 0.44

Benchmarks

C. difficile benchmark for Ontario: 0.77 per 1000 patient days
*Benchmark Source: CNISP (Canadian National Infection Surveillance Program)

What is C. difficile?

  • C. difficile is a spore forming bacterium that can live in the gastrointestinal tract.
  • It is one of the most common causes of infectious diarrhea in hospitalized patients.
  • Up to 3 – 5% of adults are colonized with C. difficile without any symptoms.
  • Regular hand washing is critical to prevent the transmission of C. difficile.

Vancomycin-Resistant Entrococcus (VRE)

Indicator Definition:

VRE Bacteraemia Rates per 1000 patient days

Incident rate of hospital-acquired infections for VRE (Vancomycin-resistant Enterococcus) per 1,000 days.

2020/2021 Quarterly Results

Quarter Cases Rate per 1,000 Patient Days
Q1 0 0.00
Q2 0 0.00
Q3 0 0.00
Q4 0 0.00

2019/2020 Quarterly Results

Quarter Cases Rate per 1,000 Patient Days
Q1 0 0.00
Q2 0 0.00
Q3 0 0.00
Q4 0 0.00

2018/2019 Quarterly Results

Quarter Cases Rate per 1,000 Patient Days
Q1 0 0.00
Q2 0 0.00
Q3 < 5 0.07
Q4 0 0.00


Benchmarks
:

VRE benchmark for Ontario: 0.01 per 1000 patient days
*Benchmark Source: CNISP (Canadian National Infection Surveillance Program)

What is VRE?

  • Enterococci are germs that live in the gastrointestinal tract (bowels) of most individuals and generally do not cause harm (this is termed “colonization”).
  • Vancomycin-resistant Enterococcus (VRE) are strains of enterococci that are resistant to the antibiotic vancomycin.
  • If a person has an infection caused by VRE, such as the urinary tract infection or blood infection, it may be more difficult to treat.
  • Regular hand washing and adherence to isolation procedures is critical to prevent the transmission of VRE.

Methicillin-Resistant Staphylococcus Aureus (MRSA) 

Indicator Definition:

MRSA Bacteraemia Rates per 1000 patient days

Incident rate of hospital-acquired infections for MRSA (Methicillin-Resistant Staphylococcus Aureus) per 1,000 days.

2020/2021 Quarterly Results

Quarter Cases Rate per 1,000 Patient Days
Q1  < 5 0.17
Q2 < 5 0.07
Q3 0 0.00
Q4 0 0.00

2019/2020 Quarterly Results

Quarter Cases Rate per 1,000 Patient Days
Q1 0 0.00
Q2 < 5 0.07
Q3 < 5 0.14
Q4 0 0.00

2018/2019 Quarterly Results

Quarter Cases Rate per 1,000 Patient Days
Q1 0 0.00
Q2 < 5 0.07
Q3 0 0.00
Q4 < 5 0.07


Benchmarks
:
MRSA benchmark for Ontario: 0.02 per 1000 patient days
*Benchmark Source: CNISP (Canadian National Infection Surveillance Program)

What is MRSA?

  • Staphylococcus aureus (S. aureus) is a germ that lives on the skin and mucous membranes of healthy people.
  • Occasionally S. aureus can cause an infection.
  • When S. aureus develops resistance to certain antibiotics, it is called methicillin-resistant Staphylococcus aureus, or MRSA.
  • Regular hand washing and adherence to isolation procedures is critical to prevent the transmission of MRSA.

Hand Hygiene Compliance Rates

Indicator Definition:

Ontario hospitals are posting their hand hygiene compliance rates as percentages for time periods identified by the Ministry of Health and Long-Term Care, using the following formula:

# of times hand hygiene performed / # of observed hand hygiene indications x 100

Hospitals are only required to publicly report the following:

  1. Hand hygiene Before Patient/Patient Environment Contact
  2. Hand hygiene After Patient/Patient Environment Contact

Annual Rate

Annual Rate 2020/21 2019/20 2018/19 2017/18
Before Patient/Patient Environment Contact 78.2% 67.4% 74.6% 77.49%
After Patient/Patient Environment Contact 82.1% 81.6% 82.8% 81.94%

For more information on the Ministry of Health and Long-Term Care’s ‘Just Clean Your Hands Campaign’ visit www.justcleanyourhands.ca.

Central Line Infection (CLI)

Indicator Definition:

The CLI rate is the number of ICU patients (18 years and older) with new CLI per 1,000 central line days. The CLI rate is calculated based on the formula below:

Total number of ICU related BSIs after 48 hours of central line placement / Total number of central line days for ICU patients (18 years and older) x 1,000

2020/2021 Quarterly Results

Quarter Cases Rate per 1,000 Patient Days
Q1 0 0.00
Q2 0 0.00
Q3 0 0.00
Q4 0 0.00

2019/2020 Quarterly Results

Quarter Cases Rate per 1,000 Patient Days
Q1 0 0.00
Q2 0 0.00
Q3 0 0.00
Q4 0 0.00

2018/2019 Quarterly Results

Quarter Cases Rate per 1,000 Patient Days
Q1 0 0.00
Q2 0 0.00
Q3 0 0.00
Q4 0 0.00


What are Central Line Infections (CLI)?

  • Central Line-Associated Primary Bloodstream Infections (CLI) occur when a central venous catheter (or “line”) placed into a patient’s vein gets infected. This happens when bacteria grow in the line and spreads to the patient’s bloodstream.
  • Patients require a central line when blood, fluid replacement and/or nutrition need to be given to them intravenously. Central lines also allow health care providers to monitor fluid status and make determinations about the heart and blood.

Symptoms of CLI include:

  • Redness, pain or swelling at or near the catheter site
  • Pain or tenderness along the path of the catheter
  • Drainage from the skin around the catheter
  • Sudden fever or chills

Ventilator Associated Pneumonia (VAP)

Indicator Definition:

The VAP rate is the number of ICU patients (18 years and older) with new VAP per 1,000 ventilator days.

2020/2021 Quarterly Results

Quarter Cases Rate per 1,000 Patient Days
Q1 0 0.00
Q2 0 0.00
Q3 < 5 1.19
Q4 0 0.00

2019/2020 Quarterly Results

Quarter Cases Rate per 1,000 Patient Days
Q1 0 0.00
Q2 0 0.00
Q3 < 5 1.29
Q4 0 0.00

2018/2019 Quarterly Results

Quarter Cases Rate per 1,000 Patient Days
Q1 0 0.00
Q2 < 5 1.15
Q3 < 5 1.15
Q4 0 0


What is VAP?

  • Ventilator associated pneumonia (VAP) is defined as a pneumonia (lung infection) occurring in patients in an intensive care unit (ICU), requiring, external mechanical breathing support (a ventilator) intermittently or continuously, through a breathing tube for more than 48 hours.
  • Patients are at risk of acquiring VAP if they have been on a ventilator for more than 5 days, have been recently hospitalized, had prior use of antibiotics (within the last 90 days), had dialysis treatment in a clinic or resided in a nursing home.

Symptoms of VAP include:

  • Fever
  • Low body temperature
  • Foul smelling infectious mucous or phlegm coughed up from the lungs into the mouth
  • Hypoxia or decreasing amounts of oxygen in the blood

Quality Improvement Plan

The Quality Improvement Plan (QIP) is a requirement under the Excellent Care for All Act, 2010. The legislation assists healthcare organizations to improve the quality and safety of care we deliver.

Quality improvement is an ongoing priority that helps us continually find new and better ways to enhance care for our clients, increase satisfaction and achieve even better clinical outcomes.

Our Quality Improvement Plan is one tool that we are using to help us document and review our current performance in a variety of areas. With this plan, we will be able to very clearly see our targeted areas for improvement and chart our progress.

St. Mary’s General Hospital is pleased to submit the Quality Improvement Plan (QIP) in the three documents outlined below.

Narrative Overview

This document provides a brief overview of our QIP priorities for the year.

Work Plan

The QIP Work Plan is a spreadsheet that summarizes our priority quality improvement targets and change initiatives for the year. Our QIP includes provincial and organizational priority indicators.

Progress Report

The Progress Report is an opportunity to demonstrate to our stakeholders the progress we have made to date on our priority indicators. It is an opportunity for us to describe our quality improvement journey and identify and discuss some of the challenges we faced in attaining the goals set out in our 2016-2017 Quality Improvement Plan (QIP).

Contact

The QIP is only one of the ways we are working to improve the patient experience.

For more information, please feel free to contact Leisa Faulkner, Vice President of Patient Services and Chief Nursing Executive.