Building a Culture of Accountability and Excellence
Thames Valley Family Health Team (TVFHT) worked hard this past year to improve how they track and report the care they provide. There was a focus placed on being more accountable by using tools like Key Performance Indicators (KPIs), better reporting systems, and a Balanced Scorecard (BSC).
A performance management system has been in place since 2021 and is unique to Thames Valley Family Health Team. Their ability to measure organization performance and show the impact they are making in their communities, has prepared them to lead major projects like the Interprofessional Primary Care Teams in London and Elgin County.
TVFHT also uses shadow coding as part of the performance management framework. This system helps to track every patient visit, diagnosis, and treatment using specific codes in the electronic medical records. It gives a clear picture of the care being provided, and where it can be improved. Shadow coding has allowed for:
- Build a strong system to measure our work
- Make better decisions about patient care
- Stay focused on our organizational goals
- Keep improving the quality of our programs and services
TVFHT Quality Coordinator Kelly McConnell shared our experience and expertise with shadow coding at the 2024 Association of Family Health Teams Ontario (AFHTO) Conference. To learn more about shadow coding, and how to start it at your organization, please email [email protected].
This careful and thoughtful approach to accountability and excellence has positioned TVFHT as a leader in primary care. Other family health teams, and their funder, Ontario Health, have asked TVFHT for advice on how to build similar systems.
How Performance Helps To Manage Our Budget
Tracking performance helps TVFHT report to Ontario Health, their Board of Directors, and the public. This data is used in TVFHT’s Quality Improvement Plan, quarterly reports, the Balanced Scorecard, and this annual report.
Right now, base budget is not directly tied to performance numbers; but that may change. Each Interprofessional Primary Care Team (IPCT) project has specific targets that must be reported to Ontario Health. If contracts start linking performance to funding, TVFHT is ready for that change.
Presenting our Performance: A Balanced Scorecard
The Balanced Scorecard is a great way to showcase accomplishments to the public and community partners.
Goals in the Balanced Scorecard come from TVFHT’s Quality Improvement Plan, as well as each team’s Key Performance Indicators.
TVFHT is proud to share the following highlights and performance improvements during the 2024-2025 fiscal year.
More Patients Followed Up After Discharge
TVFHT followed up with 4,875 patients after hospital discharge – more than double the 2,279 from the previous year!
Increase in Group Attendance
TVFHT supported 868 patients with health promotion & prevention, and mental health programs last year. That is a 23% increase in the number of attendees since last year!
Faster Access to Primary Care
More patients were able to see a provider within 24 – 48 hours. On average, 32% of patients could access care within that timeframe — up from 30% the previous year.
Respiratory Therapy Reducing Hospital Visits
The Respiratory Therapy team, in partnership with ARGI Best Care, have helped many patients avoid ER visits and hospital admissions, thereby freeing up system resources.
Note: Nurse Practitioners Shift Toward Chronic and Acute Care
TVFHT Nurse Practitioners (NPs) are focusing more on chronic disease and acute care. As they shift to a core services model, this trend is expected to continue. The decline in NP-led preventative care, like PAPs and immunizations, is tied to the Nursing team working to full scope. This change lets NPs focus on more complex patient needs.
A Note on Staffing and Output
Staffing challenges affected some of the numbers last year. For example, the Occupational Therapy team had a long vacancy, which meant fewer visits could be completed. Recruitment and retention continue to be important areas of focus, and TVFHT is working hard to build strong, stable teams to keep improving care.
Thames Valley Family Health Team
Balanced Scorecard 2024/2025