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We have a comprehensive performance management and measurement system, including regular tracking of performance indicators, which are used to guide our operational and strategic decision making to improve patient and resident care.

Following are some common indicators that we use to measure our performance and inform our improvement activities.

Percentage of elective (non-emergency) surgeries that are completed within the benchmark wait time assigned by a patient’s surgeon.

We are measuring the percent of emergency patients being admitted to the hospital who move from the Emergency Department to a hospital bed within 10 hours. Patients who were discharged home from a Clinical Decision Unit (CDU) are not included. The time spent in a CDU before a decision to admit is made does not count towards the 10 hours.

We track the amount of time our employees are away from work due to illness and divide that total by the total number of productive (working) hours.


Number of patients who get sick with the bacterium Clostridium difficilie (C. difficile) as a result of a stay in the hospital. We take the total number of health care-associated C. difficile infection cases identified every three months and divide it by the total number of patient days for the same time period. We multiply that number by 10,000 to arrive at a case rate per 10,000 patient days.

We are measuring the amount of overtime hours our staff work, as an indicator of their workload. We take the total overtime hours and divide by total productive (working) hours.

Rate of nursing sensitive adverse events for all medical and surgical patients aged 55 and older, where a patient is unintentionally harmed as a result of their medical treatment.

The Quality Improvement Composite is calculated based on fifteen quality indicators that measure functional, cognitive and continence decline as well as clinical complications. To be a truly superior facility, not only does the home have to have low rates of functional decline but it must also have low rates of clinical complications. Providence’s performance currently ranks 3rd amongst the member sites of the Seniors Quality Leap Initiative – a collaborative of 12 nursing homes across Canada and US whose vision is to become North Americas leading provider consortium for benchmarking clinical quality standards.