Quality Improvement Plan Indicator Explanation 2026-2027

For 2026, LHSC is focusing quality improvement in nine key areas with the following indicators. These indicators were identified using the feedback received from partners last year. 

	Length of Emergency Department wait for an inpatient bed Measuring the length of time waiting for a bed is a full system measure, indicating how well the hospital is working as a whole, often collected in the Emergency Department. This measure looks at the percentage of people who waited in the Emergency Department after being formally admitted into a bed or the operating room at LHSC. This is the length of time, in hours, that 90 per cent of our patients wait in the Emergency Department. A smaller number is better as it reflects a better and more efficient moving system. Our target: 20.5 hours or less.
	Emergency Department wait time to physician initial assessment​   Measuring the maximum length of time in hours patients visiting the Emergency Department wait to see a physician. This is the length of time it takes 90 per cent of patients to have their initial assessment by a physician. A smaller number is better.   Our target: Six hours or less.
	Patient experience survey question Patient experience surveys are an important way to measure how our patients feel about their experience. Our patient partners selected the following question to focus on: “Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital?”. We will know we are successful if the majority of patients select the most positive response to this question.   Our target: 65 per cent or more.
	Discharge medication reconciliation   Sharing timely information with primary care providers in the community ensures safe transitions. Many patients seek follow up care immediately post discharge from the hospital. Ensuring the best possible medication completion history (fully documenting the medications being prescribed and flagging potential interactions) is important for primary care providers to support their patients. This indicator measures how effective we are at ensuring patients medications list are reviewed and updated when they are discharged.     Our target: 80 per cent or more.
	Average Emergency Department wait time for individuals with sickle cell disease   Increase awareness of sickle cell disease (SCD) among Emergency Department staff to improve care in the Emergency Department. Work is underway to integrate care more closely with LHSC's Lifespan Hemoglobinopathy Program, which services pediatric and adult patients with SCD. The goal is to gather baseline data and help reduce the time patients with sickle cell disease (who have been identified as higher need/priority) wait for their initial physician assessment.   Our target: 45 minutes or less.
	Emergency Department wait time for patients with less urgent needs Measuring how long patients with less urgent health concerns (such as mild sprains and infections, prescription refills) spend in the Emergency Department before they are able to go home. Focusing on the length of stay for non-admitted patients. Tracking this helps us understand and improve the timeliness and flow of care for patients with lower-acuity conditions. A smaller number is better.   Our target: 5.8 hours or less.
	Emergency Department wait time for patients with urgent or serious conditions  Measuring how long patients with urgent or serious health conditions (such as shortness of breath or severe abdominal pain) spend in the Emergency Department before being able to go home. Focusing on non-admitted patients, this helps us understand how timely care is provided for patients with higher-acuity needs.  A smaller number is better.   Our target: 7.7 hours or less.
	Delirium screening with follow-up care in Hospital Measuring how often patients who are screened for delirium also receive appropriate prevention and management actions. Delirium is a sudden change in thinking or awareness that can occur during illness or hospitalization. Tracking this helps ensure that when delirium risk is identified, steps are taken to prevent it or manage it early to support patient safety and recovery. Our target: 90 per cent of screens have accompanied interventions.
	Timely safety maintenance of medical equipment and devices Measuring the number of medical devices that are overdue for scheduled preventive maintenance, with a focus on equipment that is medium to high risk. Regular maintenance helps ensure medical equipment is safe, reliable, and ready for patient care. Tracking this supports patient safety by identifying and reducing delays in completing required maintenance. Our target: 10 per cent improvement.