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 Comments
(green,
yellow,
red)
Continue prudent 1 % variance of net surplus vs budget +.7% +.7% +6 +.1 KPI A positive number indicates
fiscal management <.5% % % ▲ that we are managing with
our available resources
2 % variance of investment returns actual vs -2.3% -5.2% - - ▼ The global economy
budget <2% 2.3 1.8 negatively affected
% % investment returns for all
managed balanced funds.
3 Amount of reserve funds Minimum $3.5 $3.2 3.3 3.3 ▲
$2 million million m m
million
Develop and 4 Written/revised fund raising strategy - complet - -
implementing a completed By March ed
new fundraising 31/2011
strategy 5 % of implemented recommendations in the tbd - - - - ► Quarterly (Deferred to 2012/13
strategy 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 Comments

(green,
yellow,
red)
Continue advocacy 7 # of leaderships/policy activities involved in at the - 71 Reductions reflect
and system leadership provincial, national and LHIN levels n.a. - 45 adjustment in priorities

8 # of clients that are involved in advocacy activities n.a - 103 ► This project is in its first
- 82 year of implementation

Promote mental health 9 # of mental health promotion, workshops, presentations - 139 97 87 ▲ Annually reported
& understanding of offered within the last year 100
mental illness 10 % of staff trained in Applied Suicide Intervention Skills 33% 94.3% 95.5% 99.19 ▲
Training (ASIST) 100% %
Implement diversity 11 % of programs that completed the development of their - 100% - - ▲ Year 1 target only. This
and equity plan Diversity & Equity work-plans 100% represents clinical
programs only
12 % of staff participated in workshops - - - 65% ▼ Annually reported
80%
13 % of programs that have implemented 50% or more of 90% - - - 90% Annually reported
their Diversity& Equity work-plans
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 15 % of programs that implemented their CPI work-plans - - - 90.7 ▲ Annually reported
consumer 80% %
participation 16 Written Consumer Bill of Rights Completed Compl - - ▲
strategies document eted

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Perspective Internal Processes
Goal Develop and provide recovery based integrated services

Objective # Measure Target Q1 Q2 Q3 Q4 Status Comments

(green,
yellow,
red)
Continue service in 17 % of functional centres that fall within the LHIN - 100% 100% 81.8% KPI Two programs did not achieved
high need areas corridor for number of clients served 100% ▼ their target
aligned with our
core competence 18 % of functional centres that fall within the LHIN - 100% 100% 100% ▲ All quarterly targets have been
corridor for number of client visits 100% KPI achieved
19 % of programs at 90% capacity 90.7% 90.9% 83.3% 90.9% ▼ 10 of 11 programs met capacity
100% targets
20 % of staff that received recovery training 80% 100% - - 100% ▲

21 % of clients satisfied with service received - 87% - - KPI Annually reported

80% Target has been exceeded
Develop chronic 22 % of clients surveyed for having a chronic disease 50% - - - - Delayed start due to other
disease prevention training priorities.
and management 23 % of clients in EI and ACT who have been screened for 80% - 72% 80% ▲
options metabolic syndrome
24 % of staff that received training in chronic disease - 7% - - ▼ Delayed program start due to
management 50% other organizational training
25 # of clients receiving direct services that are involved in 40% - - - 55% Year two indicator only.
prevention activities (footcare, walking group, SMW,
Chronic Disease Management (CDM) training, diabetes
screening)
Develop concurrent 26 % of clients screened with an approved instrument - - - - Target already achieved (Year 1
disorder capacity 80% indicator only)
27 % of clients screened as having concurrent disorders tbd - - - - To be determined
receiving integrated care
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 Comments

(green,
yellow,
red)
Ensure that 29 % of staff satisfied in their current job - 87% - - KPI ▼ Annually reported
CMHA remains a 90% Based on recent
great place to accreditation survey results
work 30 % of exiting staff that voiced satisfaction/ - - 100% 100% 100% ▲ Results for satisfaction
dissatisfaction with the agency only.
31 # of paid sick days per staff 7 - 2.52 2.76 2.72 ▲

Develop Quality 32 % of formal complaints resolved as per policy - 100% - 100% ▲ This applies to service
& Safety timeline n/a complaints only. Sixteen
Improvement ( 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 36 Balanced scorecard developed Completed - - - - Document completed

Learning culture document
37 # of successful student placement within the last year 7 - 9 9 8 ▲

Achieve 38 % of ROP compliance (24/26) 100% 82% 92% 92% 100% ▲ Target is on track as
accreditation KPI 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 Accreditation
Schedule Quality
Dimensions
ACTT % of clients that have had n/a 65% n/a n/a n/a 80% Annually Effectiveness
metabolic monitoring
within the last year
% of clients with no n/a 75% 90% 84% 82% 79% Quarterly
mental health
hospitalization within the
last year (admissions
TE Nil 60% 100% 100% 100% 100% Quarterly Accessibility

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Case % of new clients receiving TW 40% 60% 100% 100% 100% 100% Quarterly Accessibility
service within intake CTO 69% 75% 94% 89% 88% 90% Quarterly Accessibility
Management benchmark MHJCM 60% 80% 40% 64% n/a n/a Quarterly Accessibility
( TE-CM,TW-
( separate targets for each MHJPP 98% 100% 100% 100%
CM,CTO,MHJ-
Prevention,, RAP team based on model of
service)
% of clients participating 40% 50% n/a 63.5% n/a Semi- Client Centred-
TE,TW,MHJCM,RAP in meaningful activities annually Services

TE,TW,MHJCM,RAP % of clients gainfully 17.2% 25% n/a 15.7% n/a Yr2 Effectiveness
employed

CTO % of clients with no 87% 90% 92% 91% 89% 85% Quarterly Effectiveness
mental health
hospitalizations within the
last year
Court % of clients that have 68% 75% n/a n/a n/a 77% Annually Effectiveness
Support been diverted within the
last year
# of clients that were 61% 65% n/a n/a n/a 71% Annually Continuity of
successfully linked to Services
services
TCM 5% increase in MCAS 53% 58% n/a 100% n/a Semi- Safety
Scores annually

Reduction in the number 4 (clients) 3 (clients) n/a 2 n/a Semi- Safety

of admission Clients annually
(hospitalization)

TRHP 7% increase in client 63% 70% n/a 100% n/a Semi- Client-Centered
satisfaction with program annually Services
activities
5% increase in MCAS 53% 58% n/a 90% n/a Semi- Safety
Scores annually

# of clients that were 61% 65% n/a n/a n/a Annually Continuity of
successfully linked to Services
services

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Intake & 10% increase in file audit 50% 60% 80% 80% 80% 80% Quarterly Safety
each session
Referral
Housing % of clients with 24mths n/a 80% 80% 75% 71% 73% Quarterly Population Focus
tenure participation
rate
20% reduction in evictions 19 (#) 20% 67% 42% 21 Quarterly

SRC & What 20% increase in the 60% 80% 82% 97.6% 100% 100% Quarterly Client-Centred
number of participants Participation
Next attending recovery based rate
education/groups
EI & TYP 3% increase in the number 77% 80% 77% 90% 100% 100% Quarterly Accessibility
of clients in school,
working or volunteering
60% increase in the 20% 80% 100% 100% 100% 100% Quarterly Accessibility
number of clients who
receive first contact with
program within 72 hours
of referral
SafeBed Decrease the turnaround 2 days 4hrs 1.24hr 1.24hr 1.65 2.11hr Quarterly Effectiveness
time for SB units
% of time that SB met the 75% 85% 100% 100% 98.5 97% Quarterly Effectiveness
4hrs
Increase the % of clients 70% 80% 100% 95.6% 100 100% Quarterly Effectiveness
that were successfully
linked to Case
Management Services
% of time that SB met the 60% 75% 73% 71% 76% 84% Quarterly Effectiveness
72hrs target for referring
clients to Case
Management Services
Employment 8% increase in clients 67% 75% 73% 94% 85 Quarterly Effectiveness
accessing available
retention days past
probationary period

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 100% increase in youth 50% 100% 34% 100% 100 Quarterly Effectiveness
referral to employment
services

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 <2% -1.8 % ▼

vs budget
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 100% 81.8% ▼

LHIN corridor for number of clients served
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 50% 7% ▼

chronic disease management

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 90% 87% ▼

job
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 100% 93% ▼

huddles

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 90% 85% ▼

hospitalizations within the last year
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 87% 85% ▼

hospitalizations within the last year
Cause(s)

Resolution

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Definitions

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

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