Improving Outcomes & Measuring our Performance

Our Balanced Scorecard provides us with a comprehensive framework for measuring organizational performance.

By reflecting on the data we receive, we can align day-to-day operations with long-term strategy and goals, and better identify areas for improvement, drive strategic initiatives, and achieve sustainable success.

A full-size version of our Balanced Scorecard is found below.

Our Metrics

Metrics in the Balanced Scorecard come from our organization’s Quality Improvement Plan as well as each team’s Key Performance Indicators.

Through shadow coding and data extraction and analysis, we are able to more accurately measure patient care activity.

These measurements provide valuable insights into the effectiveness of treatments and interventions, and identify areas for improvement in care delivery processes.

They also enable us to facilitate benchmarking against standards and best practices, fostering continuous improvement and ensuring that patients receive the highest quality of care possible.

We are proud to have implemented Shadow Coding, which allows us to input and extract data on every diagnosis, procedure, and service provided to patients. This data is included in our Balanced Scorecard.

What is Shadow Coding?

Shadow coding is a method of patient care data collection that uses the EMR bill book. Alphanumeric codes represent encounter types and applicable diagnoses, activities, and interventions for both direct and indirect patient care.

Shadow coding data offers a more accurate picture of the scope of work and the unique patient populations we serve in primary care. Shadow coding has allowed for:

  • the establishment of a comprehensive quantitative performance management system,
  • improved clinical decision-making,
  • enhanced support of our strategic directions,
  • overall continuous improvement in quality delivery of programs and services.

If you are interested in implementing shadow coding in your organization, please email [email protected].

Fast Facts from our Balanced Scorecard

Our affiliated physician partners

We are proud to be affiliated with more than 125 physicians in Elgin, Middlesex and Oxford Counties and the City of London. Our relationship is underpinned by a new agreement signed in 2023 that identifies the responsibilities for both partners.

Together we work to improve access and health outcomes for our patients. For example, we have improved access to care times for primary care in 2023/2024, but this will continue to be a focus for our team in 2024/2025.

Improving patient care after hospital discharge

Our team ensures that affiliated physicians’ patients are connected with primary care after discharge from the hospital. This helps to prevent hospital re-admissions and decreases ER visits.

Our team reviews hospital reports from Health Report Manager and Nurses contact patients to determine their needs after discharge. The patient is then referred to the most appropriate provider, which can be their family physician or one of our team members.

Enhancing medication safety and patient outcomes

Among our Clinical Pharmacists’ many responsibilities, they identify patients’ medication-related problems and work with the patient and the team to resolve them.

They also compare a patient’s current medications with new medication orders to prevent errors, especially after hospital discharge or when a patient changes providers. This helps avoid missing medications, incorrect dosages, or harmful reactions from medications.

Patient benefits include reduced hospital re-admissions as well as improved drug therapy and overall health.

Nurse Practitioners: an untapped resource

Currently, our Nurse Practitioners (NPs) support physicians in providing different types of care.

NPs treat the whole person – they look at physical and mental health, but also provide health education.

Our NPs are key to our shift to Integrated Team Care Network. In the future, they will take on patients of their own in collaboration with family physicians and lead our inter-disciplinary teams. This will allow us to expand our care to more individuals.

Enhancing mental wellness

Our Mental Health Counsellors, Social Service Workers and Psychologists provide a broad range of services, care and education that help patients with social and emotional factors that affect their health.

They assess patient needs, offer access to group programs or one-on-one counseling, provide health promotion and help patients to navigate the healthcare system.

The team helps patients manage psychosocial issues, chronic illnesses, cope with change, and stick to treatment plans by tackling challenges like financial or family issues and mental health concerns.

Empowering independence

As rehabilitation and health promotion experts, our Occupational Therapists (OTs) provide education and support to patients and caregivers.

They help improve participation in daily activities, provide exercise or equipment to improve mobility, and help with strategies to enhance functionality, independence and safety.

OTs encourage healthy lifestyle choices, help patients recover from injury, teach them how to manage chronic conditions, and identify those who need care prior to crisis or hospitalization.

Improving respiratory health (COPD and asthma care)

In partnership with ARGI Best Care, our Respiratory Therapists (RTs) have helped many patients avoid ER visits and hospital admissions, thereby freeing up system resources.

RTs apply an evidence-based, patient-centred approach to care for individuals with chronic obstructive lung disease (COPD) and asthma.

Through assessment, treatment/management and education, RTs help patients with COPD and asthma reach their care goals and increase their quality of life.

Thames Valley Family Health Team
Balanced Scorecard 2023/2024

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