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CMHA TORONTO QUALITY PERFORMANCE REPORT
Balanced Scorecard and Program Scorecard
Reporting Period: Q4- 2011-12
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PURPOSE:
To provide the Board with the first report of our efforts in strategic planning using the Balanced Scorecard (BSC)
as a management tool.
RECOMMENDATIONS
That the Board receives the report for information and discusses the performance measures
REASONS FOR RECOMMENDATIONS
In March 2010 the Strategic Plan for 2010-2013 was approved by the Board with a stipulation that quantifiable performance
metrics were needed. The report includes both organizational and programs scorecards result for the new strategic plan.
Additional measures and data may be added to future reports as we improve collection processes and systems throughout
201/13. It is also important to note that the performance report and associate measures will mature and evolve over time.
Performance thresholds may also be adjusted to reflect agency priorities and new information.
REPORT ELEMENTS
The report shows results for 39 measures measured at the organizational level, some of which are reported annually, no
immediate data. This report also includes a program level scorecard with 25 measures.
MEASURE STATUS
The status of each measure is indicated in the attached scorecards as:
● Green – equal or better than target
● Yellow – moving towards target
● Blue – in development/on track
● Red – level is below target
The summary scorecard is followed by a shortfall analysis sheet. For each of these measures, we provide explanations of why the
shortfall occurred and descriptions of resolution strategies being employed to improve performance.
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Legend Color Decision Leadership Action
Green ▲ Equal or better than target Reinforce
Yellow ► Moving towards target Stay the course
Blue ► In development/on track Continue monitoring
Red ▼ Level is below target Improvement required
n.a. Not tracked during this period
KPI Key Performance Indicator Maintain a close watch on this
Q 1 = April - June Q 2 = July - September Q 3 = October - December Q 4 = January - March
Perspective Finance
Goal Ensure sufficient resources to achieve the mission and strategic directions
Objectives # Measure Target Q1 Q2 Q3 Q4 Status
(green,
yellow,
red)
Comments
Continue prudent
fiscal management 1 % variance of net surplus vs budget
<.5%
+.7% +.7% +6
%
+.1
%
KPI
▲
A positive number indicates
that we are managing with
our available resources
2 % variance of investment returns actual vs
budget
<2%
-2.3% -5.2% -
2.3
%
-
1.8
%
▼ The global economy
negatively affected
investment returns for all managed balanced funds.
3 Amount of reserve funds Minimum $2
million
$3.5 million
$3.2 million
3.3m
3.3m
▲
Develop and
implementing a
new fundraising
strategy
4 Written/revised fund raising strategy
completed
By March
31/2011
- complet
ed
- -
5 % of implemented recommendations in the
strategy tbd - - - - ► Quarterly (Deferred to 2012/13
budget for board approval
6 % net growth in supplementary fundraising tbd - - - - ► Quarterly (Deferred to 2012/13
budget for board approval)
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Perspective Client and Community
Goal Meet client/community needs and foster inclusion
Objectives Measure Target Q1 Q2 Q3 Q4 Status
(green,
yellow,
red)
Comments
Continue advocacy
and system leadership
7 # of leaderships/policy activities involved in at the
provincial, national and LHIN levels
n.a.
- 71
- 45
Reductions reflect
adjustment in priorities
8 # of clients that are involved in advocacy activities n.a - 103
- 82
► This project is in its first
year of implementation
Promote mental health
& understanding of
mental illness
9 # of mental health promotion, workshops, presentations
offered within the last year
100
- 139 97 87 ▲ Annually reported
10 % of staff trained in Applied Suicide Intervention Skills
Training (ASIST)
100% 33% 94.3% 95.5% 99.19
% ▲
Implement diversity
and equity plan
11 % of programs that completed the development of their
Diversity & Equity work-plans
100%
- 100% - - ▲ Year 1 target only. This
represents clinical
programs only
12 % of staff participated in workshops
80%
- - - 65% ▼ Annually reported
13 % of programs that have implemented 50% or more of
their Diversity& Equity work-plans
90% - - - 90% Annually reported
14 % of programs that develop their 2nd diversity work plan
100% - - - - Year 3 indicator.
Annually reported and
only applies to direct
service teams
Develop and embed
consumer
participation
strategies
15 % of programs that implemented their CPI work-plans
80%
- - - 90.7
% ▲ Annually reported
16 Written Consumer Bill of Rights Completed
document Compl
eted
- - ▲
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Perspective
Internal Processes
Goal Develop and provide recovery based integrated services
Objective # Measure Target Q1 Q2 Q3 Q4 Status
(green,
yellow,
red)
Comments
Continue service in
high need areas
aligned with our
core competence
17 % of functional centres that fall within the LHIN
corridor for number of clients served
100%
- 100% 100% 81.8% KPI
▼
Two programs did not achieved
their target
18 % of functional centres that fall within the LHIN
corridor for number of client visits
100%
- 100% 100% 100% ▲
KPI
All quarterly targets have been
achieved
19 % of programs at 90% capacity
100%
90.7% 90.9% 83.3% 90.9% ▼ 10 of 11 programs met capacity
targets
20 % of staff that received recovery training 80% 100%
- - 100% ▲
21 % of clients satisfied with service received
80%
- 87% - - KPI Annually reported
Target has been exceeded
Develop chronic
disease prevention
and management
options
22 % of clients surveyed for having a chronic disease 50%
- - - - Delayed start due to other
training priorities.
23 % of clients in EI and ACT who have been screened for
metabolic syndrome
80% - 72% 80% ▲
24 % of staff that received training in chronic disease
management
50%
- 7% - - ▼ Delayed program start due to
other organizational training
25 # of clients receiving direct services that are involved in
prevention activities (footcare, walking group, SMW,
Chronic Disease Management (CDM) training, diabetes
screening)
40% - - - 55% Year two indicator only.
Develop concurrent
disorder capacity
26 % of clients screened with an approved instrument
80%
- - - - Target already achieved (Year 1
indicator only)
27 % of clients screened as having concurrent disorders
receiving integrated care
tbd - - - - To be determined
28 % of staff that received concurrent disorder training 80%
- 88.7% - 88.7 ▲
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Perspective Learning and Growth
Goal Develop a quality culture
Objective # Measure Target Q1 Q2 Q3 Q4 Status
(green,
yellow,
red)
Comments
Ensure that
CMHA remains a great place to
work
29 % of staff satisfied in their current job
90%
- 87% - - KPI ▼ Annually reported
Based on recent
accreditation survey results
30 % of exiting staff that voiced satisfaction/
dissatisfaction with the agency - - 100% 100% 100% ▲ Results for satisfaction
only.
31 # of paid sick days per staff 7 - 2.52 2.76 2.72 ▲
Develop Quality
& Safety Improvement
32 % of formal complaints resolved as per policy
timeline
n/a
- 100% - 100% ▲ This applies to service
complaints only. Sixteen
( 16) compliments for staff
were formally received
33 % team conducting monthly safety huddles 100% - 90% 90% 93% ▼
Only one non-clinical
program has not reported
data.
34 % of staff who received safety training 100% 93.4% 93.4% 98% ▼ 4.6% increase over the last
period
35 # WSIB Claims 4 - 4 0 1
Develop a
Learning culture
36 Balanced scorecard developed Completed
document
- - - - Document completed
37 # of successful student placement within the last year 7 - 9 9 8 ▲
Achieve
accreditation 38 % of ROP compliance (24/26) 100% 82% 92% 92% 100% ▲
KPI
Target is on track as
projected
39 QMENTUM certification – 24 months n/a - - - Achieved ▲ Accreditation status
achieved
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Program Scorecard Q4, (Jan – March 31, 2012)
Program Scorecard
January – March31, 2012 Color Decision Leadership Action
Green ▲ Equal or better than target Reinforce
Yellow ► Moving towards target Stay the course
Blue ► In development/on track Continue monitoring
Red ▼ Level is below target Improvement required
n.a. Not tracked during this period
Program KPI (not included) Key Performance Indicator Maintain a close watch on this KPI = Key Performance Indicator
Q 1 = April - June Q 2 = July - September Q 3 = October - December Q 4 = January - March
Results
Program Key Measures Baseline Target Q1 Q2 Q3 Q4 Reporting
Schedule
Accreditation
Quality
Dimensions
ACTT % of clients that have had
metabolic monitoring
within the last year
n/a 65% n/a n/a n/a 80% Annually Effectiveness
% of clients with no
mental health
hospitalization within the last year (admissions
n/a 75% 90% 84% 82% 79% Quarterly
Case % of new clients receiving TE Nil 60% 100% 100% 100% 100% Quarterly Accessibility
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Management ( TE-CM,TW-
CM,CTO,MHJ-
Prevention,, RAP
TE,TW,MHJCM,RAP
TE,TW,MHJCM,RAP
service within intake benchmark
( separate targets for each
team based on model of service)
TW 40% 60% 100% 100% 100% 100% Quarterly Accessibility
CTO 69% 75% 94% 89% 88% 90% Quarterly Accessibility
MHJCM 60% 80% 40% 64% n/a n/a Quarterly Accessibility
MHJPP 98% 100% 100% 100%
% of clients participating in meaningful activities
40% 50% n/a 63.5% n/a Semi-annually
Client Centred- Services
% of clients gainfully employed
17.2% 25% n/a 15.7% n/a Yr2 Effectiveness
CTO % of clients with no mental health
hospitalizations within the
last year
87% 90% 92% 91% 89% 85% Quarterly Effectiveness
Court
Support
% of clients that have
been diverted within the
last year
68% 75% n/a n/a n/a 77% Annually Effectiveness
# of clients that were
successfully linked to
services
61% 65% n/a n/a n/a 71% Annually Continuity of
Services
TCM 5% increase in MCAS
Scores
53% 58% n/a 100% n/a Semi-
annually
Safety
Reduction in the number
of admission (hospitalization)
4 (clients) 3 (clients) n/a 2
Clients
n/a Semi-
annually
Safety
TRHP 7% increase in client
satisfaction with program
activities
63% 70% n/a 100% n/a Semi-
annually
Client-Centered
Services
5% increase in MCAS
Scores
53% 58% n/a 90% n/a Semi-
annually
Safety
# of clients that were
successfully linked to services
61% 65% n/a n/a n/a Annually Continuity of
Services
Intake & 10% increase in file audit 50% 60% 80% 80% 80% 80% Quarterly Safety
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Referral each session
Housing % of clients with 24mths
tenure
n/a 80%
participation rate
80% 75% 71% 73% Quarterly Population Focus
20% reduction in evictions 19 (#) 20%
67%
42% 21 Quarterly
SRC & What
Next
20% increase in the
number of participants
attending recovery based
education/groups
60% 80%
Participation
rate
82% 97.6% 100% 100% Quarterly Client-Centred
EI & TYP 3% increase in the number
of clients in school, working or volunteering
77% 80% 77% 90% 100% 100% Quarterly Accessibility
60% increase in the number of clients who
receive first contact with
program within 72 hours
of referral
20% 80% 100% 100% 100% 100% Quarterly Accessibility
SafeBed Decrease the turnaround
time for SB units
2 days 4hrs 1.24hr 1.24hr 1.65 2.11hr Quarterly Effectiveness
% of time that SB met the
4hrs
75% 85% 100% 100% 98.5 97% Quarterly Effectiveness
Increase the % of clients
that were successfully linked to Case
Management Services
70% 80% 100% 95.6% 100 100% Quarterly Effectiveness
% of time that SB met the
72hrs target for referring
clients to Case
Management Services
60% 75% 73% 71% 76% 84% Quarterly Effectiveness
Employment 8% increase in clients
accessing available retention days past
probationary period
67% 75% 73% 94% 85 Quarterly Effectiveness
100% increase in youth
referral to employment
services
50% 100% 34% 100% 100 Quarterly Effectiveness
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SHORTFALL ANALYSIS – Organizational Scorecard
Shortfall Analysis Q4
Shortfall Analysis 1
Objective : Ensure sufficient resources to achieve the mission and strategic directions
Measure: # 2
Target: Result:
% variance of investment returns actual vs budget
<2% -1.8 % ▼
Cause(s) ▪ Investment returns for all managed balanced funds have been
negative due to slowdown in global economy and the Euro
debt crisis.
Resolution Investment manager has shifted asset mix away from European and
global markets
CMHA is tr Transferring monthly dividends from the balanced fund to a money
market fund, thereby moving asset mix to more conservative position
Our investment policy has a medium to long-term timeframe. Although
these short-term losses are painful, long-term strategy for a balanced portfolio should benefit over time.
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Shortfall Analysis 2
Objective : Implement diversity and equity plan
Measure: # 12
Target: Result:
% of staff who received safety training 80% 65% ▼
Cause(s) ▪ Fewer workshops offered and lower in staff participation
(workshops not filled to capacity as in previous years) because of
accreditation-related work-load in time of constraints
Resolution 9-10 workshops will be offered in 2012-13 to ensure there is
enough space for staff to attend.
Communication and coordination with managers to ensure each
training is filled to capacity will take place.
Shortfall Analysis 3
Objective :
Continue service in high need areas aligned with our core competence
Measure: # 17
Target: Result:
% of functional centres that fall within the
LHIN corridor for number of clients served 100% 81.8% ▼
Cause(s) ▪ ?
Resolution ▪ ?
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Shortfall Analysis 4
Objective : Continue service in high need areas aligned with our core competence
Measure: # 19
Target: Result:
% of programs at 90% capacity 100% 90.9 % ▼
Cause(s)
▪ Staff transition into leadership positions, turnover and maternity
coverage. This required existing case managers to cover caseload until
new staff could be hired and trained
Resolution Review staff transition process…..
Set monthly targets for new staff to increase staff caseloads to
meet/exceed program target of 90%
Shortfall Analysis 5
Objective : Develop chronic disease prevention and management options
Measure: # 24
Target: Result:
% of staff that received training in
chronic disease management
50% 7% ▼
Cause(s) ▪ Delayed program start due to staffing & resource issues
Resolution Develop a revised implementation plan
Secure funding from the LHIN
Hire required staff
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Shortfall Analysis 6
Objective : Ensure that CMHA remains a great place to work
Measure: # 29
Target: Result:
% of staff satisfied in their current
job
90% 87% ▼
Causes ▪ May be reflective of increase workload and increase stress
on the job as indicated in the accreditation work-life balance
survey. (N = 189 (down 5% from last year 2010).
▪ Wage restriction legislation
▪ Implementation of new MOHLTC initiatives
Resolution HR committee to review results/root cause
Continued dialogue with staff and managers
▪
Shortfall Analysis 7
Objective : Develop Quality & Safety Improvement
Measure: # 33
Target: Result:
% team conducting monthly safety
huddles
100% 93% ▼
Cause(s) ▪ Non-clinical programs not actively reporting that they have
conducted safety huddles
Resolution Improve communication with non-clinical teams
Create an e-reporting form.
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Shortfall Analysis 8
Objective : Develop Quality & Safety Improvement
Measure: # 34
Target: Result:
% of staff who received safety training 100% 98% ▼
Cause(s) ▪ Target has not been reached due to normal scheduling issues
Resolution Develop alternative methods for training delivery
Program Shortfall Analysis – Q4
Shortfall Analysis A
Program: CTO Objective: To Increase Program Effectiveness
Measure:
Target: Result:
% of clients with no mental health
hospitalizations within the last year 90% 85% ▼
Cause(s) ▪
Resolution
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Shortfall Analysis B
Program: Housing
Measure:
Target: Result:
% of clients with 24mths tenure 80% 73% ▼
Cause(s) 60% of discharges for long term incarcerations, hospitalizations and
death
Resolution
Shortfall Analysis C
Program: Housing
Measure:
Target: Result:
20% reduction in evictions 15 21 ▼
Cause(s) 52% for safety reasons and or long term incarcerations
Resolution
Shortfall Analysis D
Program: CTO
Measure:
Target: Result:
% of clients with no mental health
hospitalizations within the last year 87% 85% ▼
Cause(s)
Resolution
Definitions
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Terms Explanations
Balanced Scorecard An integrated framework for describing strategy through the use of linked performance measures in four, balanced
perspectives ‐ Financial, Customer, Internal Process, and Employee Learning and Growth. The Balanced Scorecard acts
as a measurement system, strategic management system, and communication tool.
Financial Perspective One of the four standard perspectives used with the Balanced Scorecard. Financial measures inform an organization whether strategy execution, is leading to improved bottom line results.
Client/Community Perspective One of the four standard perspectives used with the Balanced Scorecard. Measures are developed based on the answer
to two fundamental questions ‐ who are our target customers and what is our value proposition in serving them?
Internal Process Perspective One of the four standard perspectives used with the Balanced Scorecard. Measures in this perspective are used to
monitor the effectiveness of key processes the organization must excel at in order to continue adding value for stakeholders.
Learning and Growth Perspective One of the four standard perspectives used with the Balanced Scorecard. Measures in this perspective are often considered "enablers" of measures appearing in the other three perspectives.
Measure A standard used to evaluate and communicate performance against expected results.
Objective A concise statement describing the specific things an organization must do well in order to execute its strategy.
Perspective In Balanced Scorecard vernacular perspective refers to a category of performance measures
Target Represents the desired result of a performance measure. Metabolic syndrome Metabolic syndrome is the name for a group of risk factors linked to overweight and obesity that increase your chance for heart
disease and other health problems such as diabetes and stroke. The term “metabolic” refers to the biochemical processes involved in
the body's normal functioning. ...
www1.cardiotabs.com/glossary.asp
KPI Key Performance Indicator