Quality Improvement Plan 2017-18

Our quality improvement plan (QIP) sets the goals and priorities for improving the quality of care we provide to patients. This is a key plan for ensuring a quality patient experience.

The 2017/18 QIP represents an exciting milestone and opportunity for Scarborough and Rouge Hospital (SRH) — a newly-merged organization currently in a period of transition. This is the organization’s first QIP, and it sets the stage for establishing SRH as a high-performing, patient-centered provider of excellent quality care.

SRH was formed on December 1, 2016, bringing together the Birchmount and General sites of The Scarborough Hospital (TSH) and the Centenary site of Rouge Valley Health System (RVHS). All three sites brought with them strong quality-improvement programs that have provided a firm foundation for SRH to develop this QIP.

Scarborough and Rouge Hospital (SRH) 2017/18 Quality Improvement Plan

More information on QIPs

Quality improvement plans are legislative requirements. The Excellent Care for All Act (2010) is meant to promote a culture of continuous quality improvement in health care, where the needs of patients come first. Through this Act, the Ontario government requires many health-care organizations and providers to develop a QIP every year, and make that plan available to the public. This includes all hospitals; as well as primary care organizations, like teams of family doctors and community health centres; Community Care Access Centres that look after home care; and long-term-care homes.

These plans are an opportunity to highlight an organization’s commitment to:

  • Delivering high-quality health care;
  • Creating a positive patient experience;
  • Ensuring that it is responsive and accountable to the public;
  • Holding its executive team accountable for its achievement; and,
  • Being transparent.

For more information on QIPs, please visit:

Ministry of Health and Long-Term Care

Health Quality Ontario

Quality and Patient Safety Plan 2016-2017

The purpose of the Quality and Patient Safety Plan is to create and sustain high quality, safe care. It is meant to help identify the risks to patient safety, actions to help reduce these risks, and guide the organization in maintaining a continuous focus on quality improvement processes and systems.

The Quality and Patient Safety Plan recognizes that all aspects of the organization have an impact on quality and safety: leadership, governance, staff, physicians, patients, and families. As well, workplace health initiatives, such as staff culture, organizational development, staff competencies, training, education, and organizational health impact on our core business of patient care.

The 2016-2017 Quality and Patient Safety Plan builds on The Scarborough Hospital’s 2015-2019 Strategic Plan and assists the hospital in meeting important requirements for Accreditation.


Accreditation is an internationally recognized and respected evaluation process used by many countries worldwide to assess the quality of health services.

Health and social service organizations that participate in Accreditation Canada’s program are evaluating their performance against national standards of excellence. These standards examine all aspects of health care, from patient safety and ethics, to staff training and partnering with the community.

Organizations like The Scarborough Hospital voluntarily participate in the accreditation program. They devote time and resources to learn how to improve what they are doing so they can provide the best possible care and service to their patients and clients.

The Accreditation Canada certificate shows that the organization cares about patient safety and providing quality service. It means the organization was assessed by its peers, met or exceeded national standards of excellence, and continues to strive for high quality health care.

The Scarborough Hospital most recently achieved a full three-year accreditation in November 2012. For more information on this process, please see the Accreditation Canada website at A copy of the Accreditation Canada report is available online.

Balanced Scorecard

A balanced scorecard is a framework that translates strategic directions into a set of performance measures that help indicate how well an organization doing.  It is called “balanced” because ideally, the scorecard should include measures from all aspects of the business, and should include both long and short-term indicators.

The TSH balanced scorecard includes measures from each of our four strategic directions. Some of the measures were chosen specifically by TSH’s executive team while others are publicly reported indicators that TSH is mandated by the province to include. Obviously, a balanced scorecard cannot measure every aspect of a business, but overall, it is a good indicator of an organization’s strengths and weaknesses.

TSH’s scorecard, which is updated quarterly, is presented to The Scarborough Hospital’s Board of Directors who uses it to monitor the progress of the hospital. It is also posted on the hospital’s website  as part of TSH’s commitment to transparency and public accountability.

Each indicator includes a target or benchmark and the red, yellow and green colour coding tells viewers at a glance whether or not TSH is meeting the benchmark. Where an indicator is not meeting the benchmark an action plan is created. This plan outlines activities and programs that have been started to ensure that performance improves on that indicator.

Review the The Scarborough Hospital’s Balanced Scorecard.


C. Difficile

The Scarborough Hospital is committed to delivering safe, high-quality care to all the patients that we serve. To this end, we carefully monitor important patient safety measurements, including rates of Clostridium Difficile (C. difficile).

To demonstrate our commitment to patient safety and to transparency, we have made this information available to the public since the spring of 2008. The Ministry of Health and Long-Term Care made it a requirement for Ontario hospitals to report these statistics monthly as of September 26, 2008.


C. difficile is a common bacterium that lives in the intestinal tract of many healthy people. Use of antibiotics sometimes changes the bacterial flora or population of the intestinal tract, allowing the C. difficile bacteria to grow out of proportion. In doing this, the bacterium secretes a toxin that attacks the lining of the intestinal tract .The patient may get diarrhea or even more serious illness.

While C. difficile does not usually present a big problem for reasonably healthy adults, it can be quite serious for those who are frail or have other health challenges.

C. difficile is communicable. It can live in the environment and on other surfaces. Rigorous cleaning regimes, patient isolation and hand washing are some of the strategies used to combat C. difficile.

Older hospitals across the province, including the General, face greater challenges in combating C. diff due to structural issues such as fewer hand washing sinks, waste management systems that need upgrading and fewer single patient rooms. Because of these challenges, TSH has initiated a number of programs including random infection control audits, a hand ashing campaign on-going staff education and rigorous environmental cleaning.

In addition, Dr. Michael Gardam, a recognized expert in C. difficile and the province’s new Director of Infectious Disease Prevention and Control for the Ontario Agency for Health Promotion and Protection, conducted an independent review of The Scarborough Hospital’s infection control practices. Recommendations from his August 2008 report are currently being implemented at the General campus.

The Scarborough Hospital’s C. Difficile Rates


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 healthcare providers to monitor fluid status and make determinations about the heart and blood.

The Scarborough Hospitals Central Line Infections.


Hand Hygiene Compliance

The single most common way of transferring health care-associated infections (HAIs) in health care settings is on the hands of health care providers. Health care providers move from patient to patient and room to room while providing care and working in the patient environment. This movement provides many opportunities for the transmission of organisms on hands that can cause infections. Proper hand hygiene will protect patients and providers and will reduce the spread of infections and the associated treatment costs, reduce hospital lengths of stay and readmissions, reduce wait times, and prevent deaths.

The Scarborough Hospital’s Hand Hygiene Compliance Rates.


Hospital Standardized Mortality Ratio (HSMR)

Dedication of physicians and frontline staff, along with a focus on improving quality of care, has meant dramatic improvements to the Hospital Standardized Mortality Ratio (HSMR) at The Scarborough Hospital (TSH). Our 2010-11 rate was the best in the city of Toronto, demonstrating a remarkable improvement over our historic results.

HSMR is considered a “big-dot” summary measure that is used to track a hospital’s mortality over time. The HSMR is a tool that allows hospitals to measure and monitor their progress in quality of care.

What is HSMR?

Hospital Standardized Mortality Ratio (HSMR) is a new measure of patient safety that compares a hospital’s mortality rate with the average Canadian rate. It examines observed versus expected deaths and is adjusted for various factors including age, sex, diagnoses and admission status of patients.

The calculation
HSMR = Actual number of deaths among diagnosis groups accounting for 80% of inpatient mortality *100
Expected number of deaths among diagnosis groups accounting for 80% of inpatient mortality

Adjusted for:

  • Age
  • Sex
  • Length of Stay
  • Admission Category
  • Diagnosis Group
  • Comorbidity (using Charleson Index)
  • Transfers

An HSMR score of 100 indicates the number of actual deaths was equal to the number of expected deaths.

Why is it important for hospitals to track HSMR?

HSMR is one of a number of important quality and safety measures designed to improve patient care. In a tangible way, many hospitals use measures like HSMR to develop action plans to monitor performance improvement and reduce mortality rates. Some hospitals have used HSMR to identify coding issues within their organizations and have added the measure in their accountability frameworks or balanced scorecards.

The Scarborough Hospitals HSMR Rates.


Methicillin Resistant Staphylococcus Aureus (MRSA)

Methicillin Resistant Staphylococcus Aureus (MRSA) is a bacterium that has developed a resistance to the antibiotics that were once commonly prescribed to kill it. Many healthy people have these bacteria on their body (most commonly in their nose) not causing harm which is called colonization. When a person has the bacteria in their urine, or in any other site that should be sterile (e.g. lung, blood )this is called an infection.

MRSA can be spread to other people by close contact between colonized or infected persons or the bacteria can be picked up in the environment and transferred to a person. To prevent the spread of these bacteria, a person who is colonized or infected with MRSA is placed under isolation precautions and all who care for that patient including the patient themselves must practice excellent hand hygiene either with soap and water or alcohol hand rub.

The Scarborough Hospital’s MRSA rates are very good; well below the provincial average at both sites.

The Scarborough Hospital MRSA Rate.


Surgical Safety Checklist

A surgical safety checklist is a patient safety communication tool that is used by a team of operating room professionals (nurses, surgeons, anesthesiologists, and others) to discuss important details about each surgical case. In many ways, the surgical checklist is similar to an airline pilot’s checklist used just before take-off. It is a final check prior to surgery used to make sure everyone knows the important medical information they need to know about the patient, that all equipment is available and in working order, and that everyone is ready to proceed.

The checklist is considered “performed” when the designated checklist coordinator confirms that surgical team members have implemented and/or addressed all of the necessary tasks and items in each of the three phases: Briefing; Time Out; and Debriefing. Therefore, the SSCL compliance indicator is a process measure, measuring the degree to which all three phases of the SSCL were performed correctly and appropriately for each surgical patient.

The Scarborough Hospital Surgical Safety Checklist.


Surgical Site Infections

Surgical site infections occur when harmful germs enter a patient’s body through the surgical site (any cut the surgeon makes in the skin to perform the operation). Infections happen because germs are everywhere – on the skin, in the air and on things individuals touch. Most infections are caused by germs found on and in a patient’s body.

One of the ways to prevent surgical site infections is by giving patients antibiotics 0 to 60 minutes (for usual antibiotics) or 0 to 120 minutes (for an antibiotic known as vancomycin) before they go into surgery.

The Scarborough Hospitals SSI Rates.


Ventilator Associated Pneumonia (VAP)

Ventilator associated pneumonia (VAP) is defined as pneumonia (a serious lung infection) that can occur in patients, specifically those in Intensive Care Units (ICU) who need assistance breathing with a mechanical ventilator for at least 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

The Scarborough Hospitals VAP Rates.


Vancomycin-Resistant Enterococcus (VRE)

Enterococci are bacteria found normally in the intestinal tract. When vancomycin (an antibiotic) is unable to kill these bacteria, the bacteria is called VRE.

VRE can survive on hard surfaces for many days and on hands for hours. Good hand hygiene with soap and water or with alcohol hand rub is the best way to stop the spread of VRE.

The Scarborough Hospital’s VRE rates are extremely low due to our aggressive screening program.

The Scarborough Hospital VRE Rate.