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An environmental scan of public domain reporting on injury and trauma in British Columbia Alhoshan, Raiyan Khaleel 2015

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  AN ENVIRONMENTAL SCAN OF PUBLIC DOMAIN REPORTING ON INJURY AND TRAUMA IN BRITISH COLUMBIA  by  Raiyan Khaleel Alhoshan A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE IN SURGERY in The Faculty of Graduate and Postdoctoral Studies (Surgery) THE UNIVERSTIY OF BRITISH COLUMBIA (Vancouver)  August 2015 © Raiyan Khaleel Alhoshan, 2015    ii Abstract Introduction: High quality trauma care and effective injury prevention and control in regionally discrete populations are prime objectives of mature trauma systems. In British Columbia, where 4.6 million people inhabit a vast area of one million square kilometers, numerous independent agencies and organizations with varying performance objectives guided by large independent data collection strategies support this collective effort. Whole system measures are an emerging evaluative tool useful to decision makers responsible for allocating resources to better align and integrate healthcare delivery services that result in meaningful system-level performance improvement. The usefulness of current performance reporting to drive improvement in the design and function of British Columbia’s systems of trauma care and injury management is unclear. Objectives: The research objectives were to (1) describe in qualitative and semi-quantitative terms the depth and breadth of public domain reporting on injury management in the province of British Columbia; (2) identify, if possible, measures that describe performance of the system as a whole; and (3) identify performance reporting gaps that, if addressed, may facilitate improvement in system design and function. Methods: (1) Identify all B.C agencies involved in the care, control and prevention of injury; (2) Identify performance objectives for the provincial trauma system through assessment of the strategic plans of leading trauma organizations; (3) Construct an inventory of public domain reporting by identified agencies; (4) Describe retrieved reports using qualitative and semi-quantitative methods; (5) Compare performance reporting output against overarching strategic performance objectives to identify gaps in whole system reporting.  iii Results: We identified 276 injury-related performance measures from 19 data sets in 174 reports produced by 37 B.C. organizations from 1998-2013. All 13 domain trauma system were represented. Unadjusted mortality and stratified incidence rates from surveillance reporting predominated. EMS, acute hospital care and recovery care reporting was thin. While several metrics could be adopted as whole system measures, important gaps were identified.  Conclusion: Public reporting of trauma care and injury management in B.C. does not reflect an integrated system unified by well aligned outcome objectives. A whole system measures approach to performance evaluation of the provincial trauma system could help to accomplish this.  iv Preface This dissertation is original and unpublished work. Mark Dalgarno is acknowledged for initial work to identify trauma and injury-related organizations used to establish the inventory of public reports used in this study. Dr. David Evans, and Mark Dalgarno designed the data abstraction tool used to collect data in this project. The background research and data collection, synthesis, analysis and interpretation are my original work.    v Table of contents Abstract .......................................................................................................................................... ii  Preface ........................................................................................................................................... iv Table of contents ........................................................................................................................... v  List of figures .............................................................................................................................. viii List of abbreviations .................................................................................................................... ix  Glossary ........................................................................................................................................ xi  Dedication ................................................................................................................................... xiii 1 Introduction ........................................................................................................................... 1 1.1 The organization of trauma care and injury control in British Columbia ........................... 2 1.2 Importance of performance reporting ..................................................................................... 5 1.3 Approach to performance reporting ........................................................................................ 5 1.4 The need for whole system measures ....................................................................................... 6 1.5 The whole system measures approach ..................................................................................... 8 1.6 Research objectives.................................................................................................................... 9 2 Methods ................................................................................................................................ 12  2.1 Identification of injury-relevant organizations in British Columbia (step 1) .................... 12 2.2 Identification of provincial trauma system performance objectives (step 2) ..................... 13 2.3 Development of an inventory of public domain reporting on injury care, control and prevention in British Columbia (step 3) ............................................................................................. 14 2.4 Evaluation of retrieved reports (step 4) ................................................................................. 15 2.4.1 Defining the variables of interest ........................................................................................... 15 2.4.2 Description of terms used as variables .................................................................................. 18 2.4.2.1 Report identification ................................................................................................................... 18 2.4.2.2 Data source identification ........................................................................................................... 18 2.4.2.3 Report characteristics ................................................................................................................. 18 2.4.2.3.1 Descriptive ............................................................................................................................. 19 2.4.2.3.2 Analytic ................................................................................................................................. 19 2.4.2.3.3 Applied .................................................................................................................................. 19 2.4.2.3.4 Evaluative .............................................................................................................................. 19 2.4.2.4 Performance metrics ................................................................................................................... 19 2.4.2.5 Identification of whole system measures ................................................................................... 19 2.5 Data extraction ......................................................................................................................... 20 2.5.1 Describing trauma system domains ....................................................................................... 21 2.5.2 Categorizing performance measures according to IOM dimensions ..................................... 21 2.5.3 Identification of feasible system-level performance measures. ............................................. 22 2.6 Identification of gaps in whole system reporting (step 5) .................................................... 22 3 Result .................................................................................................................................... 24 3.1 Trauma system domains ......................................................................................................... 24 3.1.1 Prevention and research ......................................................................................................... 24 3.1.2 Health authority organizations ............................................................................................... 24 3.1.3 Government ........................................................................................................................... 24 3.1.4 Public health .......................................................................................................................... 25 3.1.5 Research ................................................................................................................................. 25 vi 3.1.6 Municipal services ................................................................................................................. 25 3.1.7 Prevention .............................................................................................................................. 25 3.1.8 Public insurance ..................................................................................................................... 25 3.1.9 Pre-hospital service ................................................................................................................ 25 3.1.10 Others ..................................................................................................................................... 26 3.2 How are trauma system domains captured in public-reporting? ....................................... 28 3.3 Extent of analysis in performance reporting on trauma and injury in B.C. ...................... 30 3.4 The distribution of data sources used in performance reporting ........................................ 30 3.5 Number and distribution of metrics according to IOM dimensions of quality: ................. 32 3.6 Identification of system-wide measures for reflecting provincial priorities of trauma care and injury management ....................................................................................................................... 35 4 Discussion............................................................................................................................. 41 4.1 How to improve whole system level reporting ...................................................................... 47 4.2 Build a system level performance measure ........................................................................... 48 4.3 Conclusion ................................................................................................................................ 48 4.4 Study limitations ...................................................................................................................... 49 5 Summary .............................................................................................................................. 50 References .................................................................................................................................... 52  Appendices ................................................................................................................................... 83 Appendix A: Compendium of performance measures identified in reports surveyed ................... 83 Appendix B: Inventory of surveyed reports ..................................................................................... 102 Appendix C: Data abstraction tool ................................................................................................... 110    vii List of tables Table 2.1 Inclusion and exclusion criteria ............................................................................. 15 Table 2.2 List of variables for data abstraction – report identification ............................. 16 Table 2.3 List of variables for data abstraction – report characteristics ........................... 17 Table 3.1 Inventory of public domain injury management reports in British Columbia . 27 Table 3.2 Analysis of information reported by trauma system domain ............................. 29 Table 3.3 Distribution of performance measures over 6 IOM quality dimensions ............ 33 Table 3.4 Provincial priorities of trauma care and injury management ............................ 36 Table 3.5 Applicability of current performance measures to trauma system priorities ... 37 Table 3.6 Identified performance measures in B.C.’s public reporting ............................. 39    viii List of figures Figure 2.1 Flow diagram of report inclusion and exclusion .............................................. 23 Figure 3.1 Trauma system domains represented in retrieved reports ............................. 28 Figure 3.2 Distribution of data source used in performance reporting ........................... 31 Figure 3.3 Distribution of performance measure over 6 IOM quality dimension ........... 34    ix List of abbreviations  ASMR            Adjusted standardized mortality rate  BCCDC  B.C. Center of Disease Control BCTR  B.C. Trauma Registry CIHI  Canadian Institute for Health Information DAD  Discharge Abstract Database DR-EP Disaster Response – Emergency Preparedness FHA  Fraser Health Authority FNHC  First Nation Health Council  ICBC  Insurance Corporation of British Columbia IOM Institute of Medicine (Division of U.S. National Academy of Sciences, Engineering and Medicine) JIBC Justice Institute of British Columbia LOS  Length of stay  MVC  Motor vehicle collision  MVI  Motor vehicle incident  NRS  National Rehabilitation Reporting System NTR  National Trauma Registry PHO  Office of the Provincial Health Officer PHSA  Provincial Health Services Authority x RCMP Royal Canadian Mounted Police  UHRI  Urban Health Research Initiative VCH  Vancouver Costal Health  VIHA  Vancouver Island Health Authority  Vital stat B.C. Vital Statistics Agency WSM  Whole System Measures  xi Glossary  1. Trauma system domains: The operational continuum of injury care in B.C. consisting of multiple domains that, when combined, create the trauma system.  2. Pre-hospital care: Care provided to the patient by emergency medical services (EMS) prior to hospital arrival. 3. Acute care: Emergency and definitive medical care provided for acute injury in hospital facilities often designated as trauma receiving hospitals, but not necessarily so. 4. Injury prevention: Effort to reduce or prevent injury caused by external means, such as accidents, often done by British Colombia Prevention and Research Unit (BCIPU). 5. Research: Research conducted on injury care and found in public trauma reports. 6. Education: Special training health care personnel had in trauma care. 7. Emergence preparedness: Disaster preparation plans created to reduce susceptibility to hazards, earthquakes, fires and floods, often prepared and updated by Emergency Management B.C. 8. Financial aspects: The financial consequences of injury. 9. Rehabilitation: The stage where patients receive help in regaining their physical activities or gaining maximum self-sufficiency after acute care. 10. Domain of organization: The area of activity the organization is responsible for and its role in the continuum of injury care 11. Performance measure: A numeric quantification of healthcare performance for a designated healthcare provider, such as hospital, health plan, nursing home, clinician, etc.  12. Safe care: Avoiding injuries to patients resulting from professional care. An example of a safe measure would be Rate of adverse effect (Wolfe, 2001). xii 13. Effective care: Providing services to those likely to benefit in accordance to scientific know-how. Mortality Rate is an example of and effective measure (Wolfe, 2001). 14. Patient-centered care: Providing care that is patient-oriented and value-based. A Patient Satisfaction Rate is an example of such measure (Wolfe, 2001). 15. Timely care: Eliminating time wasting strategies that are both harmful to the patients and the hospital staff, an example is the wait time to triage (Wolfe, 2001). 16. Efficient care: Avoiding wastage that is measured by ex; Health cost per capita (Wolfe, 2001). 17. Equitable care: Providing unbiased care to all patients despite their race or ethnicity (Wolfe, 2001). 18. Accountability: An obligation or willingness to accept responsibility for performance (National Quality Form, n.d).  xiii Dedication    To my parents, who have dedicated their lives to help me excel and become the man I am.  1  1 Introduction Injury is the leading cause of death and loss of active years of life for people under the age of 40. 4.27 million Canadians aged 12 or older experienced an injury severe enough to limit their daily activities. In fact, injury sends 25,500 children under the age of 14 to hospitals every year. This costs Canadians almost 20 billion dollars each year. (Billette, Janz. 2011). In B.C. alone, approximately 2,300 people die each year due to injury, costing 5 billion dollars a year and making injury the third largest expense in the province’s health sector (Provincial Health Services Authority (PHSA), 2014a, 2015b). Injury is not accidental, but the result of unmanaged circumstances, often in at-risk individuals. As such, it is considered preventable. Common mechanisms of injury include motor vehicle crashes, cyclist and pedestrian incidents, falls, as well as violent crime including gunshots and stabbings (National Highway Traffic Safety Administration, 2004). In addition to avoidable loss of life, injury results in lost time from work, long-term disability, significant burden on the health care system, as well as emotional and physical distress for patients and families.  Modeled on military experience, organized trauma systems have been established throughout the developed world over the past 40 years to stabilize and rapidly transport severely injured patients to definitive care in designated and appropriately resourced trauma receiving facilities (Evans, 2007). Recent research from the United States confirms that organized trauma systems reduce injury-related death by up to 25% (Mackenzie, 2006).  2 While the main focus of trauma systems is providing timely and effective acute medical care to severely injured patients across an injury-to-recovery continuum, which encompasses pre-hospital emergency medical services (EMS), acute hospital-based care and post-hospital rehabilitation. The scope of activity of trauma systems has expanded over time to address many other aspects of population-based injury control (Evans, 2007). These include injury surveillance and prevention, disaster preparedness, advocacy, policy development, regulation, education, and research (Mock, 2004; National Highway Traffic Safety Administration, 2004).  Conceptually, these domains can be viewed as discrete but interconnected domains of a whole system, all of which require strong leadership and adequate resource allocation by strategically aligned decision makers. According to the Trauma Association of Canada accreditation guidelines (TAC, 2011), a fully comprehensive and inclusive trauma system is a preplanned, organized, and coordinated injury control effort in a defined geographic area. 1.1 The organization of trauma care and injury control in British Columbia Trauma Services B.C, the provincial oversight organization for trauma care in B.C., defines a trauma system in its 2014 Strategic Plan as “a coordinated, preplanned, publicly accountable, operationally integrated effort that (1) enhances community health by delivering care across the continuum to all injured patients that is effective, timely, appropriate, equitable, high-quality, cost-efficient, and safe, and (2) operationally links with emergency preparedness planning and the public health system through injury surveillance, prevention, advocacy and policy development to minimize the overall burden of injury in the population in a defined geographic region." (Trauma Service B.C, 2014, p. 4). 3 Currently in B.C., coordinated injury care is provided by five geographic regional health authorities working with the province’s single emergency medical service (EMS) provider, B.C. Emergency Health Services (BCEHS). Each health authority has designated trauma centers at different levels of capability brought together under the leadership of regional trauma programs. BCEHS oversees the B.C Ambulance Service (BCAS) and the B.C. Patient Transfer Network (BC PTN), the provincial patient transport system. PHSA also oversees specialized pediatric care by the B.C. Children’s Hospital, the B.C. Injury Research and Prevention Unit (BCIRPU) which is affiliated with the Children’s Hospital, and the B.C. Centre for Disease Control which is expanding its mandate to include injury surveillance and prevention.  PHSA created Trauma Services B.C. (TSBC) in 2012 as an oversight body to promote coordinated and effective trauma care throughout the province. In addition, TSBC manages the B.C. Trauma Registry (BCTR) which collects standardized data on the province’s most severely injured patients admitted to B.C.’s 11 designated trauma centers. This data is intended to provide important information on the B.C. trauma system as a whole and to drive quality improvement, system decision-making, and research in individual centers.  The British Columbia Ministry of Health sets priorities for public health through its annual service plans (Ministry of Health, 2013) and other strategic documents. It also provides funding to the health regions who establish regional programs that reflect these directives in their own service plans (PHSA, 2013), as they respond to local needs.  The provincial government also influences health system performance directly and indirectly through its various other agencies. The Office of the Provincial Health Officer and the regional Medical Health Officers, for example, oversee public health issues including 4 preventable injury. Moreover, the B.C. Coroners Service works to understand circumstances of death where injury is frequently a cause, and makes policy recommendations to the government. The Insurance Corporation of British Columbia (ICBC) is a public crown corporation that insures automobile related claims and produces the majority of data on motor vehicle related injury. Likewise, WorkSafe B.C. investigates and insures work-related injury claims. It also collects extensive data used to inform regulation of workplace safety. Another major government organization influencing health system performance is the Provincial Emergency Preparedness Program which leads emergency preparedness and disaster response planning focusing on the management of mass casualties as would occur in an earthquake, bus crash, or public event incidents. Trauma Services B.C. envisions a provincial trauma system that strongly aligns the many organizations that influence the understanding and management of injury among the general population with the organizations that care for injury, notably major trauma, at the patient level. Its vision is that “British Columbia will enjoy the lowest burden of injury in North America” (PHSA, 2014, p. 4), which implies a coordinated effort to both treat injured patients effectively and prevent the occurrence of injury and/or reduce its severity. This further implies a need to understand and measure the outcomes of these activities as well as the involved processes.  The mandate of Trauma Services B.C. is to “assure optimal performance of the B.C. trauma system” (PHSA, 2014, p. 4). Similarly, this implies a definition of performance including targets or benchmarks based on performance indicators. It also requires a clear definition of ‘the system’ and how it operates. As of yet, there is no organizational description of the B.C. trauma system that details functional integration of these many organizations around trauma care and 5 injury management. Therefore, it is difficult to clearly define the system and, more importantly, even more challenging to define its performance expectations.  1.2 Importance of performance reporting  Public reporting on performance is one of the most essential steps towards system improvement (Foot, Ross, 2010). It helps researchers find gaps in the performance or implement innovative strategies in redesigning the system (Marshall, Shekelle, Leatherman, Brook, 2000). Also, public reporting motivates hospitals to improve their work compared to other hospitals (Hibbard, Stockard, Tusler, 2003). Therefore, it is useful to examine how the National Health Service (NHS) benefits from reporting on performance.  The NHS in England is administered by the government and is a major healthcare provider in England. A recent overhaul of procedures in the NHS has resulted in a shift away from process targets (indicators) towards health outcomes as a measure of performance. This is based on the idea that the old system presented health care priorities that looked more like a quality framework (National Health Service, 2009). Meanwhile, several reviews of the Australian health system have suggested that, like the NHS, the health system was too focused on service outputs (process measure) rather than patient outcomes, and recommended linking performance indicators to desired health outcome (Council of Australian Governments Reform Council, 2010a, 2011b). 1.3 Approach to performance reporting Ideally, data required to develop performance measures have to be reported and collected regularly. The B.C. Trauma Registry collects data from different sources including the patient hospital medical record and B.C. Ambulance service information from pre-hospital and inter-6 facility transport or transfer events. Registrars then encrypt and categorize this information for analysis and reporting. British Colombia Trauma Registry (BCTR) provides healthcare providers, leaders, and researchers with cleaned data that can help them understand and improve patient care and system performance (Trauma Registry Information Specialists of Canada, 2010; Provincial Health Services Authority, 2014).  One of the challenges facing the trauma system is that it requires a high level of cooperation between many different agencies and sectors ranging from higher-level decision makers to dispatchers (Mock, 2004). For example, patient over-triage to unnecessary high-level acute facilities leads to increase in costs (Newgard et al., 2013). However, lack of clarity and transparency in public reporting might affect the performance of the system in different ways (Fanjiang, Grossman, Compton, Reid, 2005). For example, a recent audit of Air Ambulance B.C. has shown that the objectives were not clear, which lead to a gap between the goals intended and the current outcomes. Other recommendations were made about measuring timeliness, safety, and patients’ experience of air transport, as well as to share the results gathered with stakeholders. Therefore, more performance reporting accountability is required (Office of The Auditor General of British Colombia, 2013). The coordination of efforts in reporting, data gathering, and analysis required should be done through an integrated framework or agenda implemented by all the parties involved (Mock, 2004).  1.4 The need for whole system measures   There has been increasing emphasis in the development and use of performance measures that comprehensively summarize the effectiveness of the health service delivery systems for large populations. Today, the performance of the health care system is not solely viewed from the provider’s point of view or the patient’s point of view, but also from the decision-makers’ point of 7 view (Fanjiang, Grossman, Compton, Reid, 2005). Many decision-makers, including the Auditor General of B.C., require a clear framework that measures quality, timeliness and safety in the service (Office of the Auditor General of British Colombia, 2013). This perspective considers the system in its entirety as opposed to focusing merely on the provider’s perspective. Accordingly, when considering measurement of the performance of an entire trauma system, we should implement measures that reflect the performance of the whole system or what we call ‘system-level measures’ rather than the performance of segregated processes within the system. This is especially important when measurement of a system’s performance is limited to the provider’s perspective, as most often is the case. Such use of whole-system measures will help develop a meaningful and balanced scorecard. This scorecard of measures will focus on measuring the outcomes intended by decision makers instead of the outcomes intended at the providers-level or the subsystem-level (Fanjiang, Grossman, Compton, Reid, 2005; Martin, Nelson, Lloyd, & Nolan, 2007). To improve the health system, B.C.’s health sector has recently adopted three priorities suggested by the United States Institute for Health Improvement (IHI) called the Triple Aim. These priorities are; improving the health of the population, improving the patient experience of care, and finally, reducing the per capita cost of health (Ministry of Health, 2015). The Triple Aims are interdependent of each other, meaning that pursuing any one aim may positively or negatively affect the other two aims. Therefore, new improvement initiatives should consider and yield a balance between these three aims (Berwick, Nolan, Whittington, 2008). According to World Health Organization (WHO), a convincing, operational and balanced framework is vital in assessing health system performance for the work of governments and the development of 8 agencies and multilateral institutions. We suggest that a clear performance measurement system of B.C.’s trauma system is needed. 1.5 The whole system measures approach We propose a Whole System Measures (WSM) approach to developing a measurement framework that views performance at the system-level and is potentially capable of providing health care decision makers with information that will allow them to evaluate the health system performance. It consists of a small set of measures (13 measures) that are at the system-level. This approach was developed on the idea that any set of measures must reflect a balance between structures, outcomes, and process (Donabedian, 1980a, 1982b; Kaplan, Norton, 1996). It also uses measures that are neither disease nor condition-specific. Authors of “Whole Systems Measures”, Martin, Nelson, Lloyd, & Nolan (2007), have found that a balanced set of measures will provide leaders and stakeholders with longitudinal data on the performance of health care system. This allows for comparison between similar organizations and serves as input to strategic planning. We have chosen this approach to measure the Triple Aim because both the WSM and the Triple Aim were constructed upon the idea that the health care system should be evaluated from six different dimensions: The six Institute of Medicine (IOM) Dimension of Quality (Berwick, Nolan, Whittington, 2008; Martin, Nelson, Lloyd, & Nolan, 2007). In 2001, the Institute of Medicine suggested six aims of care as dimensions of quality when considering new quality measurement methods of the health care system. These dimensions were implemented by leading public health agencies including the Institute for Health Improvement (IHI) as a fabric to help develop new performance metrics and to construct a balanced performance measurement framework. They also help health care agencies, 9 policymakers, health care leaders and clinicians in balancing the focus of quality of care among all dimensions of care (Martin, Nelson, Lloyd, & Nolan, 2007).  According to U.S. Institute of Medicine (IOM) in 2001, the six dimensions of quality are: a. Safe: Avoiding injuries to patients resulting from professional care. An example of a safe measure would be rate of adverse effect. b. Effective: Providing services to those likely to benefit in accordance to scientific know-how. Mortality Rate is an example of and effective measure. c. Patient-centered: Providing care that is patient-oriented and value-based. Patient Satisfaction Rate is an example of such measure. d. Timely: Eliminating time wasting strategies that are both harmful to the patients and the hospital staff. An example is the wait time to triage. e. Efficient: Avoiding wastage that is measured by health cost per capita, for example. f. Equitable: Providing equitable care to all patients despite their race or ethnicity. So, optimal performance at the macro level reflects high-level measures at the micro level. This is similar to the WSM approach which states that if the trauma system was performing well at optimal alignment and integration of the numerous agencies and organizations, it is likely to be performing well at lower levels whose measures roll up and reflect into the high-level measures. If the best possible results are not being achieved, then it is necessary to dig deeper into the causal system to identify how and where the processes of care need to be improved. 1.6  Research objectives In this research, we hope to better understand the performance objectives associated with organized trauma care and injury control activities in B.C. We postulate that these would be 10 reflected through organization-specific reporting in the public domain. The Auditor General of British Columbia mandates that publicly funded organizations, such as those described above for trauma and injury, demonstrate public accountability through performance reporting. The Auditor General recently criticized both the B.C. Ambulance Services for inadequate performance reporting on its costly air medical evacuation program (Office of The Auditor General of British Colombia, 2013), and Health Emergency Management B.C. for the absence of satisfactory demonstration of effectiveness in achieving its organizational objectives in disaster response planning (Office of The Auditor General of British Colombia, 2014).  By looking collectively at public domain reporting produced by trauma-related organizations in British Columbia, we will be able to estimate how closely currently available data allows Trauma Services B.C. to come to a whole-system view of the broadly defined B.C. trauma system it endorses. We will also be able to describe the indicators or metrics used, their data sources and potential gaps in performance reporting where more effort may be required to provide a comprehensive picture of how well organized injury management works in B.C. The use of measures describing outcomes and processes consistent with the strategic directives of government and other organizations working to influence injury is important to document, as is any evidence that the reporting of these measures actually leads to analysis that generates recommendations for system change that measurably influences outcomes that are important. A well-integrated trauma system should be built to achieve favorable health outcomes through the treatment of severely injured patients and population level injury control by finding ways to improve system function such as though better communication between organizations. This should be the direct focus of reporting on performance. (American College of Surgeons, 2014; Fanjiang, Grossman, Compton, Reid, 2005; Marshall, Shekelle, Leatherman, Brook, 2000) 11 The objectives of this research are to: 1. Describe in qualitative and semi-quantitative terms the depth and breadth of public domain reporting on injury management in British Columbia. 2. Identify, if possible, measures that describe performance of the system as a whole. 3. Identify performance reporting gaps that, if addressed, may facilitate improvement in system design and management.  12 2 Methods In order to complete an environmental scan documenting the nature of trauma and injury reporting in the public domain by agencies and organizations responsible for injury care, control and prevention in the province of British Columbia over the fifteen-year period 1998-2013, the steps described below were taken.  2.1 Identification of injury-relevant organizations in British Columbia (step 1) The major domains of organized trauma/injury management as used in commonly descriptions of trauma care systems (American College of Surgeons, 1999) were categorized as follows:  (i) Governance / leadership (government) (ii) Public agencies (insurance, worker’s compensation)) (iii) Pre-hospital emergency medical services (EMS) (iv) Acute facility-based care (hospitals/trauma centres) (v) Post-acute recovery (rehabilitation and convalescent care) (vi) Public health (injury surveillance)  (vii) Injury prevention  (viii) Disaster response and emergency preparedness (DR-EP) (ix) Municipal services (police, fire, search and rescue) (x) Policy and regulation  13 (xi) Advocacy (special interest / non-profit groups) (xii) Education  (xiii) Research  Agencies and organizations in B.C. that fit within the described domains and would be considered potential sources of public reporting on injury care and control were then identified. This was accomplished through questioning of key informants familiar with injury and major trauma management in B.C. Organizations that affirmed or implied a role in injury care, control and/or prevention were included as key informants. To develop as complete a list as possible, the websites of named organizations were explored to identify partners, affiliate organizations, directories, and links that may also be considered eligible for inclusion in the environmental scan.  2.2 Identification of provincial trauma system performance objectives (step 2) In order to describe the overarching priorities and goals of the provincial system of trauma care and injury management, we sought high level strategic documents published by the B.C. Government Ministry of Health and the Regional Health Authorities. It was assumed that these agencies, as funders of the system, could be regarded as the ultimate system decision makers responsible for setting system priorities and performance expectations. We explored the websites of these agencies and searched the web using common browsers and search engines (Google ™) to identify relevant documents. The most recent documents available that described government and health authority priority setting in broad terms for coming years were retrieved.  14 2.3 Development of an inventory of public domain reporting on injury care, control and prevention in British Columbia (step 3) We identified the websites of organizations involved in trauma service reporting using a standard browser and search engine (Google ™) and then searched for potentially eligible reports using key words such as injury, trauma, disaster/emergency preparedness, prevention and death. We followed these organizations for additional publications that were related to trauma service in B.C. Reports that did not account for trauma or injury care were excluded. The descriptive approach used to evaluate reporting was based on an existing framework for describing organizational reporting. An inventory was compiled of operational, strategic, performance, and informational reports produced by identified organizations and that were available in the public domain. The most recent reports were selected from the 15-year period from 1998 to 2013. Selection criteria used in identifying appropriate reports for this study are listed in Table 2.1.  Operational, strategic, informational and performance categories were defined according to the Performance Reporting Principles and Guidelines (Treasury Board Secretariat Treasury Board Secretariat, 2008). Operational reports were those presenting granular up-to-date data reflecting specific processes in support of the ongoing operation of a system or program (Treasury Board Secretariat, 2008). They are retroactive reports used by administrators and managers directly responsible for improving operations. Strategic reports, on the other hand, were defined as those describing and responding to perceived situations that are intended to guide program development in terms of capacity and policy and often compare measures over time (Treasury Board Secretariat, 2008). They are proactive reports used by planners and often contain a value proposition of what an organization is and what it aspires to achieve. Moreover, 15 Informational reports present summarized data over protracted timelines that may serve an analytical purpose; but, more often, provide only a general overview of a program or situation that is non-granular and incomplete. Finally, Performance reports present performance or quality indicators reflecting key activities over time, often with comparison to a desired standard.  Table 2.1 Inclusion and exclusion criteria Include  Exclude   From 1998-2013  Publicly available by internet web search (Google search)  Related to Trauma in BC  Pertinent to at least one of the principal domains of trauma care and injury management  Repeated annual or older version reports    2.4 Evaluation of retrieved reports (step 4) The strategy outlined below was used to evaluate the retrieved reports. 2.4.1 Defining the variables of interest A list of variables of interest was developed in accordance with our objective of describing and documenting how injury considerations were expressed, quantified and communicated in the public domain reports. Tables 2.2 and 2.3 below, list all the variables we collected in our data abstraction tool. Refer to Appendix C for a screen shot of the tool used. 16 Table 2.2 List of variables for data abstraction – report identification Report identification Variable Sub-variable 1  Report name   2  Report file name   3  Report level 1 National 2 Provincial 3 Regional 4 Hospital 5 Program 6 Other 7 Unknown 4  Health region  1 Northern Health Authority 2 Interior Health Authority 3 Vancouver Island Health Authority  4 Vancouver Costal Health Authority 5 First Nation Health Authority 6 Fraser Health Authority 7 Provincial Health Services Authority 5  System domain 1 Government - national 2 Government - provincial 3 Government - municipal 4 Pre-hospital (EMS) 5 Hospital – acute care 6 Post-hospital - recovery 7 Injury prevention 8 Public agencies 9 Municipal services 10 Public health 11 Emergency preparedness 12 Advocacy 13 Education 14 Research 15 Other 15 Unknown 6  Organization name  7  Year published  8  Years covered in report  9  Number of pages  10  Report frequency 1 Annual 2 Ad hoc 3 Cannot say Data source  11  Referenced data source (s) 1 Discharge abstract dataset 2 Trauma Registry 3 Government Census 4 Pre-hospital (EMS) 5 NACRS 6 NRS 7 CIHI 8 Coroner 9 Other  17 Table 2.3 List of variables for data abstraction – report characteristics Report characteristics Variable Sub-variable 12  Quality aspect  1 Structural - immovable 2 Structural - human resources 3 Structural – operational strategy 4 Process 5 Outcome 13  Report type 1 Strategic  2 Operational 3 Informational 14  No. of times ‘trauma’ cited  15  No. of times ‘injury’ cited  16  No. of times ‘prevention’ cited  17 Domain / Information cited 1-1  EMS (reference only) 1-2  EMS (analysis) 1-3  EMS (recommendation) 1-4  EMS (change evaluation) 2-1  Hospital care (reference only) 2-2  Hospital care (analysis) 2-3  Hospital care (recommendation) 2-4  Hospital care (change evaluation) 3-1  Recovery care (reference only) 3-2  Recovery care (analysis) 3-3  Recovery care (recommendation) 3-4  Recovery care (change evaluation) 4-1  Prevention (reference only) 4-2  Prevention (analysis) 4-3  Prevention (recommendation) 4-4  Prevention (change evaluation) 5-1  Research (reference only) 5-2  Research (analysis) 5-3  Research (recommendation) 5-4  Research (change evaluation) 6-1  Education (reference only) 6-2  Education (analysis) 6-3  Education (recommendation) 6-4  Education (change evaluation) 7-1  DR-EP (reference only) 7-2  DR-EP (analysis) 7-3  DR-EP care (recommendation) 7-4  DR-EP care (change evaluation) 8-1  Cost/Finance (reference only) 8-2  Cost/Finance (analysis) 8-3  Cost/Finance (recommendation) 8-4  Cost/Finance (change evaluation) Metrics Performance measures cited   18 2.4.2 Description of terms used as variables  While many variables collected are self-explanatory, some require clarification: 2.4.2.1 Report identification  Report identification variables identify the report and include such information as report title, date, organization represented and file name. Report level refers to the audience and entity in the health care system that was targeted in the report. With respect to report frequency, some reports were produced on a yearly basis and described as ‘Annual reports’. Other reports were one time only which we assigned as ‘Ad hoc’. 2.4.2.2 Data source identification  We created a variable to identify the data sets supporting the information presented. We took note of formally managed free-standing provincial and national databases used for statistical reporting and research. We also recognized administrative and operational databases used by organizations to manage and describe activity.  2.4.2.3 Report characteristics We adapted the classic Donabedian framework (Donabedian, 1988) for quality evaluation and to describe which domains of activity or business the retrieved reports described with respect to trauma care and injury management; namely, structures, processes or outcomes. Structures were subcategorized into (i) fixed assets such as equipment and facilities, (ii) human resources such as paramedic or medical personnel, and (iii) operational strategies including institutional protocols that have been constructed to govern approaches to management and operative decision-making.  We developed an approach to assessing the manner in which data was used to communicate information about the systems described using the following framework: 19 2.4.2.3.1 Descriptive  The data presented serves a descriptive or informational purpose only and is not sufficient without further analysis to guide system-level performance improvement action.  2.4.2.3.2 Analytic  The data presented has been adjusted, stratified or contextualized in some way to provide understanding as to whether or not the data are precise or meaningful enough to guide system-level performance improvement action. 2.4.2.3.3 Applied  The data are presented to support a recommendation for action that would be viewed as system-level performance improvement. 2.4.2.3.4 Evaluative  The data presented communicate evaluation of an implemented intervention designed to result in system-level performance improvement (loop closure). 2.4.2.4 Performance metrics  Performance metrics were extracted manually by two different researchers. Key descriptors of the metrics were attributed, including data source, tabulations, format, how often they were collected, and whether the data were used in a descriptive, analytic, applied or evaluative way, as described above. References to performance standards, benchmarks or other comparators were also noted.  2.4.2.5 Identification of whole system measures  A system-level measure should measure the overarching organizational performance goals articulated by individual organizations. We considered recommended performance measures from health authorities only if they had recommended system-level measures. We also have evaluated the applicability of the current reported performance measures to the priorities 20 the health authorities have set for the trauma system (Table 3.6). We evaluated their applicability according to our understanding of the definitions of the performance measures. Applicable (Yes) means the performance measure aligns with the health authorities’ priorities for the trauma system and is a mandate of the trauma care system. Not applicable (No) means the performance measure does not align with the priorities of the trauma system set by health authorities. For some performance measures (+/-), it was unclear whether they align or are specific to the mandate of the trauma system. Refer to Appendix A for further details. In an effort to assess whether any of the compiled list of retrieved metrics could be used as ‘whole system measures’ in a manner similar to those formally described by the U.S. Institute of Medicine for the comprehensive evaluation of hospital performance, we adopted the IOM WSM framework from the hospital level and applied it to a geographically defined region of trauma care and injury control (Table 3.5). Estimations were made as to whether it was likely, unlikely or possible that the IOM hospital-level performance categories could be applied to a larger regional system, and the considerations we determined as being important for this to feasibly occur were noted for each indicator. We then set out to map the reported measures identified by our research onto this framework.  2.5 Data extraction Reports were obtained using a search engine (Google™ ) from the websites of trauma/injury-related organizations in B.C. Collected reports were searched for the terms: ‘injury’, ‘trauma’, ‘prevention’, ‘disaster’, ‘emergency’, ‘performance measure’, ‘performance indicator’, ‘crash’, ‘fall’, ‘suicide’, and ‘assault’. Reports were then examined to determine whether or not they contained statistical measures or performance measures. Those presenting statistical measures or citing performance measures were examined to further categorize the 21 metrics as descriptive, analytic, applicative (supporting recommendations) or evaluative (assessing the implementation of recommended system changes). Data from each report was collected in an MS Access ® data base and transferred to an MS Excel ® spread sheet for data cleaning and analysis. 2.5.1 Describing trauma system domains In our analysis, we focused on certain aspects of trauma care, or what we call domains of trauma. These domains include pre-hospital care, acute care, rehab, injury prevention, research and education, emergency preparedness, as well as the financial aspects of care. We examined whether the reports have mentioned, analyzed, recommended, or followed up on any of the domains. 2.5.2 Categorizing performance measures according to IOM dimensions  Each performance measure identified was categorized into one or more of the six IOM quality domains. First, safe measures address avoiding injuries to patients resulting from professional care. Second, effective measures mean providing services to those likely to benefit in accordance to scientific know-how. Third, patient-centered measures are those providing care that is patient-oriented and value-based. Fourth, timely measures are the ones interested in eliminating time wasting strategies that are both harmful to the patients and the hospital staff. Fifth, efficient measures are those that address avoiding wastage of resources. Lastly, equitable measures address providing equitable care to all patients despite their race, ethnicity, gender, geographic location, and socioeconomic status (Wolfe, 2001). After a careful consideration of the ‘Six IOM Dimensions of Quality’ definitions, we were able to manually categorize the performance measures according to the defined IOM dimension they reflect (Wolfe, 2001).  22 2.5.3 Identification of feasible system-level performance measures. We used the WSM scorecard to guide us on suggesting system-level performance measures that could be relevant in the context of provincial reporting. We also considered the current data collection efforts in order to make suggestions on how to modify current reporting efforts to achieve the listed measures (Table 3.5). 2.6 Identification of gaps in whole system reporting (step 5) We have used the priorities framework we found in the strategic reporting (step 2) and mapped them against the performance measures we collected (step 4) to identify possible gaps in public reporting. Every leading trauma organization in B.C. report their goals and priorities in strategic reports and provide performance measures that reflect these goals. However, the goals and measures may not be specific to trauma. Therefore, we focused on how these priorities and goals are being considered in injury care specifically. We also identified, in Appendix A, possible performance measures that would reflect these goals.  23 Figure 2.1 Flow diagram of report inclusion and exclusion  24 3 Result 3.1 Trauma system domains Our environmental scan identified 37 organizations and 408 reports, of which 174 were considered eligible for our study after screening for inclusion (Figure 2.1). Studies were included only if they focused solely on B.C. and were published between 1998 and 2013. To ensure that our research focused on the most up to date performance information, we used the most recently published reports available up to 2013. We categorized these reports in terms of the principal domain of activity that they represent. Besides health authority organizations, 60% of our reports came from nine organizations in just two domains - prevention and research (Table 3.1): 3.1.1 Prevention and research  Just under a third of our reports came from two organizations (B.C. Coroner service and B.C. Injury and Prevention Unit) with 58 reports published between 2005 and 2013; making it the largest group in our inventory. 3.1.2 Health authority organizations  A full quarter of our reports were published by health authority organizations which include Northern Health, Interior Health, Vancouver Coastal Health, Vancouver Island Health, Fraser Health, Provincial Health Services, and the First Nations Health Council. Between 2005 and 2013, 45 published reports were categorized in this domain. The remaining 40% of our reports came from a wide variety of organizations distributed among the remaining eight domains, with the majority originating from governmental sources. 3.1.3 Government  Governmental agencies that reported on injury or trauma in B.C. included the Ministry of Health, Ministry of Justice, Ministry of Transport and Infrastructure, Ministry of Community, 25 Sports, and Cultural Development and the Office of the Ombudsman. This domain included 25 reports published between 2005 and 2013. 3.1.4 Public health  A total of 11 reports were included from the years 2003 to 2013 from two public health organizations including the B.C. Center of Disease control and Office of the Provincial Health Officer. 3.1.5 Research  Six organizations were included (Statistics Canada, CIHI, Mastic, BC Vital Statistics, Urban Health Research Initiative, National Trauma Registry, Center for Addiction Research of BC), with 12 reports added from the years 2001 to 2013. 3.1.6 Municipal services  Five reports were extracted from Vancouver Police Department, Vancouver Fire and Rescue and Royal Canadian Mounted Police, all published between 2011 and 2013. 3.1.7 Prevention  Four reports were added in this domain from WorkSafe B.C. between the years 1998 to 2013. 3.1.8 Public insurance  Only three reports published in 2013 were included from Insurance Corporation of B.C. (ICBC).  3.1.9 Pre-hospital service  Only two reports were included in our inventory from B.C. Ambulance Service and Provincial Emergency Service project. The former was published in 2003 and the latter in 2011. 26 3.1.10 Others  Other reports identified included reports from single organizations such as Vancouver Area Network of Drug Users.  We have excluded 20 reports that did not discuss trauma or injury in depth. The remaining 154 reports were then analyzed as shown below.   27 Table 3.1 Inventory of public domain injury management reports in British Columbia Domain Organization No. of reports Year published From To National agencies Canadian Institute for Health Information / NTR  2  2013 Statistics Canada 5 2002 2013 Provincial government Ministry of Health 11 2005 2012 Ministry of Justice – B.C. Coroners Service 29 2007 2013 Ministry of Justice – Other 6 2012 2013 Ministry of Public Safety and Solicitor General 3 2009 2011 Ministry of Transportation and Infrastructure 2  2013 Ministry of Community, Sport and Cultural Development 2  2013 Office of the Ombudsman 1 2012 2012 BC Vital Statistics Agency 2 2011 2012 BC Health Services Purchasing Organization 1  2013 Public agencies Insurance Corporation of British Columbia 3  2013 Worksafe BC 4 1998 2013 Health authorities Northern Health Authority 9 2007 2013 Interior Health Authority 8 2007 2013 Vancouver Island Health Authority  4 2008 2013 Vancouver Costal Health Authority 6 2008 2013 First Nation Health Authority 2 2005 2012 Fraser Health Authority 6 2010 2012 Provincial Health Services Authority 10 2008 2012 Public health Office of the Provincial Health Officer 9 2003 2012 BC Center of Disease Control 2 2012 2013 EMS BC Ambulance Service 1  2011 Emergency preparedness Provincial Emergency Services Project 1  2003 Injury prevention BC Injury Research and Prevention Unit 29 2005 2013 Smartrisk 1  2001 Municipal services Vancouver Fire and Rescue 2 2011 2012 Vancouver Police Department 1  2011 Royal Canadian Mounted Police  2 2012 2013 Research Urban Health Research Initiative 1  2009 Centre for Addictions Research of BC 1  2006 Education Justice Institute of BC 4 2010 2013 Advocacy Clinical Prevention Policy Review Committee 1  2009 RoadHealth Coalition 1  2009 Vancouver Area Network of Drug Users 1  2010   28 3.2 How are trauma system domains captured in public-reporting? Reports were examined across the trauma system domains as shown in Figure 3.1. This histogram shows the percentage of reports that mentioned or analyzed different trauma system domains. Some reports mentioned more than one domain of the trauma system while others mentioned only one. As shown in Figure 3.1, the most common trauma system domains referenced in the retrieved reports were injury prevention and acute hospital care. Each of these domains were presented in nearly half of the reports. The domains of rehabilitation/recovery services, research and finance were referenced in approximately 20% of the reports while education was referenced in 26% of the reports. Education here refers most commonly to recommendations in workforce training. Only 10% of the reports referenced pre-hospital and emergency preparedness. Figure 3.1 Trauma system domains represented in retrieved reports  0%10%20%30%40%50%60%70%80%90%100%Trauma Domains29 Table 3.2 below outlines the number of times the individual domains of the trauma system were mentioned, analyzed, and/or referred to in recommendations or follow up evaluations of implemented interventions designed to improve preferred outcomes. Among the reports we analyzed, pre-hospital care, disaster management, rehabilitation services and costs were among the least prevalent domains; whereas injury prevention, and acute hospital care were the most prevalent. For example, although pre-hospital care was mentioned in 22 reports, there were only two references to analysis, one to recommendations for future performance improvement, and no reference to evaluation of implemented changes. Injury prevention, on the other hand, was mentioned in 103 reports, analyzed in 32, referred to with respect to recommendations for changes in 48, and followed up on in six reports. Research and education fell in the middle ground with research being mentioned in 39 reports while education was mentioned in 44. Table 3.2 Analysis of information reported by trauma system domain Trauma system domains Description Analysis Application (Recommendation) Evaluation Pre-hospital 22 2 1 0 Acute hospital care 81 27 14 5 Rehabilitation 29 6 8 2 Injury prevention 103 32 48 6 Research 39 13 25 1 Education 44 8 24 1 Disaster management 22 4 3 2 Financial 38 7 2 2    30 3.3 Extent of analysis in performance reporting on trauma and injury in B.C. The reports were analyzed to ascertain whether they had metrics. We found that 97 of the reports had performance metrics in them while 57 did not. We further investigated the reports with metrics to see if they had actually analyzed or provided sufficient information about the reported performance measures of the trauma domains we showed earlier. We found that more than 51% of the reports did not analyze the data, while fewer than 49% did. 3.4 The distribution of data sources used in performance reporting Figure 3.2 shows the distribution of data sources among the 97 reports that had performance metrics. 19 reports were not included in this chart (16 with no sources found while the remaining three reports were found to be studies). More than 75% of the data were provided by four (4) data sources: B.C. Coroner Service (the leading data source with 25% performance metrics), followed by B.C. Vital Statistics with 24%, Discharge Abstract Database having 15% and ICBC covering 12% of the data. The remaining data, which account for approximately 24%, were provided by 15 different sources; namely, Canadian Hospitals Injury Reporting and Prevention Program with 5%, B.C. Vital Statistics Agency with 3%, and Northern Health Authority, BC Injury Research and Prevention Unit, Ministry of Health, Public Health Agency of Canada and Center for Addiction Research of B.C. all having 2% performance metrics, respectively. Whereas the rest of the data sources; namely, B.C Trauma Registry, Transport Canada, Daycare Service Playground Injury Data, WorkSafe, National Trauma Registry, Population Health Surveillance and Epidemiology, Hospital Morbidity Database and VISTA have contributed 1% each.   31 Figure 3.2 Distribution of data source used in performance reporting   BCCS, 25%NTR ,1%worksafe , 1%bc stat, 3%daycare service playground …bc vital , 24%Transport Canada, 1%BCTR, 1%DAD, 15%,Centre for Addictions Research of BC, 2%, Public Health Agency of …VISTA , 1%,CHIRPP, 5%Icbc, 12%,Hospital Morbidity Database, 1%MOH, 2%Population Health Surveillance and Epidemiology, 1%BCIRPU, 2%, NHA, 2%32 3.5 Number and distribution of metrics according to IOM dimensions of quality: In the reports we identified, we found 276 different performance measures each with at least one and as high as 15 different stratifications applied such as gender, sex, age, mechanism of injury, case, township, region, month and time. They were counted as one performance measure if they serve or measure the same interest. After a thorough examination of the performance measures and a careful consideration of the IOM “six dimensions of quality” definitions, we categorized the performance measures by IOM dimensions of quality of care. Given the fact that these dimensions of quality often share common objectives, it was challenging to distinguish the quality dimension of each performance measure. Indeed, the dimensions of quality are not mutually exclusive and a single performance measure can be described in multiple dimensions.  Figure 3.3 shows the total number of metrics categorized according to IOM dimensions of quality. The number of performance measures shown in this graph is 415 - well over 276. This is due to the overlapping between dimensions, as explained above. The most represented dimension was effectiveness, with over a third of performance measures (175) in this category. This was followed by equitability with 113 performance measures found in this dimension, representing just over a quarter of all performance measures. Efficiency was identified in 75 performance measures. The other 3 quality dimensions were found significantly less in the reports, representing only 11% of all performance measures when combined. More specifically, 29 safe measures, 19 patient-centered care measures and only 2 timely measures were identified (Table 3.3).   33 Table 3.3 Distribution of performance measures over 6 IOM quality dimensions  IOM Dimension Number of metrics Percentage  Effective 151 37% Timely 2 .5% Efficient 99 24% Patient-centered 19 4.5% Safe 26 6.4% Equitable 113 28% *Categories are not mutually exclusive 34 Figure 3.3 Distribution of performance measure over 6 IOM quality dimension   * IOM dimensions definitions found in glossary 1757519292113020406080100120140160180200Effective Efficient Patient centered care safe Timely Equitable35 3.6  Identification of system-wide measures for reflecting provincial priorities of trauma care and injury management  Table 3.4 shows a tabularized synthesis of overarching health system priorities and goals applicable to trauma care and injury management put forward in recent key documents of the B.C. Government Ministry of Health (Ministry of Health, 2013a, 2015b), the Provincial Health Services Authority (PHSA) and the Vancouver Coastal Health Authority (as representative of the other health regions) which must align their strategic priorities with those of the government and PHSA (PHSA, 2013; VCH, 2013). A synthesis of the system goals and performance objectives of these organizations was completed and is represented in tabular form.  There were three measures recommended for injury prevention priorities by B.C.’s Health Ministry that translated to a system level. These measures are 1) the age-standardized hospitalization rate for unintentional injuries, 2) the age-standardized mortality rate for unintentional injuries and 3) the age-standardized rate of fall-related hospitalization for British Columbians aged 75 and over. Other possible whole system measures that align with health authorities’ priorities are listed in Appendix A. See table 3.5 for more details. 36 Table 3.4 Provincial priorities of trauma care and injury management  Source  Priority theme  Recommended system- level metrics  B.C. GOV Ministry of Health (Ministry of Health, 2013a, 2015b) Triple aims:  1-more effective care for general population 2- better patient experience, and provider experience 3-improve per capita cost  No measures found (look at Appendix A for applicable performance measures for these aims) Improve access of care to rural areas No measures found (not even in Appendix A) Improve access to acute surgery No measures found (not even in Appendix A) Injury prevention  1-The age-standardized hospitalization rate for unintentional injuries 2-The age-standardized mortality rate for unintentional injuries 3-The age-standardized rate of fall-related hospitalization for British Columbians aged 75+ PHSA (PHSA, 2013) 1-Effective health promotion, prevention and self-management to improve the health and wellness of British Columbians. 2-British Columbians have access to high quality hospital services when needed. 3-Improved innovation, productivity and efficiency in the delivery of health services  No system wide measures found (look at Appendix A for applicable performance measures for these aims) Vancouver Costal Health Authority (VCH, 2013) 1-support the health and wellbeing of VCH residents 2-Deliver a system of responsive and effective health care services across VCH 3-Innovate to ensure value for money and sustainability No system wide measures found (look at Appendix A for applicable performance measures for these aims) B.C Ambulance Service (BCAS, 2011) 1-Improve patient care 2-improve coordination between parties involved in trauma system  No system wide measures found (look at Appendix A for applicable performance measures for these aims) 37 As shown by Table 3.5, out of the 274 performance measures identified, three were not applicable whereas 249 were applicable and 22 were possibly applicable. The most prevalent applicable performance measures were mortality, hospitalization, and injury rate. However, the applicability of the claims measure was unclear because 10 out of 11 were general to the society level. Refer to Appendix A for more details.  Table 3.5 Applicability of current performance measures to trauma system priorities Type of measure   Number of applicable whole system performance measures  Not applicable performance measures  Number of possible applicable performance measures  Injury rate 28 1 4 Mortality  96 0 4 Hospitalization  29 0 0 Length of stay  18 0 0 Claims 1 0 10 Cost  13 2 2 Timely 2 0 0 Others  15 0 2 Patients experience survey 15 0 0 Morbidity  6 0 0 Disability-adjusted life years 0 0 2 Potential years of life lost due to injury 0 0 3 Hospital separation 10 0 0 Hospital transfer 2 0 0 Hospital visits  9 0 0    38 We have used the whole system measure’s balanced scorecard, as a tool to identify possible reliable and useful measures specific to trauma system. Table 3.6 lists all the 13 measures recommended by the IHI in measuring the whole system. The measures we found in B.C.’s public reporting include Work Related Injury and Unadjusted Raw Mortality Percentage. Also, Health Care Cost Per Capita is reported by SmartRisk (2008) in “Economic Burden of Unintentional Injury in British Columbia”. Both Patient Satisfaction with Care Score and Patient Experience Score are reported by the Ministry of Health and provincial health authorities in a Report called Patient Experiences with Acute Inpatient Hospital Care in B.C. These measures are reported in “Our Health Care Report Card 2013”. The measures not found include Rate of Adverse Events, which is the harm caused to the patients by the hospital or any health entity to the patients. Also not found are Functional Health Outcomes Score, Reliability of Core Measures, Days to Third Next Available Appointment, Hospital Days per Decedent During the Last Six Months of Life, Hospital Standardized Mortality Ratio (HSMR) and Hospital Readmission Percentage.  39 Table 3.6 Identified performance measures in B.C.’s public reporting Whole System Measure  Measures found in BC public reporting   IOM Dimension of quality 1. Rate of Adverse Events  Safe 2. Incidence of Nonfatal Occupational Injuries and Illnesses  Safe 3. Hospital Standardized Mortality Ratio   Effective 4. Unadjusted Raw Mortality Percentage  Effective 5. Functional Health Outcomes Score  Effective 6. Hospital Readmission Percentage   Effective 7. Reliability of Core Measures   Effective 8. Patient Satisfaction with Care Score  Patient- Centered 9. Patient Experience Score  Patient- Centered 10. Days to Third Next Available Appointment  Timely 11. Hospital Days per Decedent During the Last Six Months of Life   Efficient 12. Health Care Cost per Capita  Efficient 13. Equity (Stratification of Whole System Measures) * Equitable = Found measure. = Not found. * Measures of equity are found by stratifying other measures.40 Table 3.7 Feasibility of using IOM whole system measures as performance measures for a regionalized trauma system IOM Whole System Measure proposed for hospital-level evaluation  Useable for population-level evaluation? Considerations 1. Rate of Adverse Events YES Relates only to in-hospital patient care. Could collect from hospital reporting systems. These are inconsistent across sites. Need to incorporate non-hospital adverse events, 2. Incidence of Nonfatal Occupational Injuries and Illnesses YES Need to define the workforce 3. Hospital Standardized Mortality Ratio  YES Could be generated across all hospitals. Preferable to adjust for injury severity (ISS) also 4. Unadjusted Raw Mortality Percentage YES Need to capture out of hospital death (merge hospital and coroners data sets) 5. Functional Health Outcomes Score POSSIBLE Would require a system of evaluation and data collection that does not currently exist 6. Hospital Readmission Percentage YES Could be generated by focusing on injury care patients  7. Reliability of Core Measures YES Define the processes in the organization for which will measure reliability  8. Patient Satisfaction with Care Score POSSIBLE Would require a system of evaluation and data collection that does not currently exist 9. Patient Experience Score POSSIBLE Would require a system of evaluation and data collection that does not currently exist 10. Days to Third Next Available Appointment POSSIBLE Would require a system of evaluation and data collection that does not currently exist 11. Hospital Days per Decedent During the Last Six Months of Life YES Would require a system of evaluation and data collection that does not currently exist 12. Health Care Cost per Capita YES Need to capture all the injury care domains  13. Equity (Stratification of Whole System Measures) YES Would require stratifying system level measures we have by sex, age, region, and economical states.  41 4 Discussion  Public reporting is an important tool used by decision makers to demonstrate accountability for the achievement of high-level performance objectives in publicly managed systems. As articulated by the B.C. Auditor General in a recent review of the B.C.’s air medical transport system and emergency preparedness programs, it is a reasonable expectation that all health system performance be acceptably evaluated and reported to the public (Office of The Auditor General of British Colombia, 2013). The self-declared mission of Trauma Services B.C., as the newly established provincial oversight body for trauma systems in B.C. is to assure the optimal performance of the B.C. trauma system. This necessarily requires operational alignment of the performance objectives of the B.C. Government’s ministries (Health, Justice, Transportation) and agencies (ICBC, WorkSafe B.C.), and the regional and provincial health authorities responsible for care delivery throughout the province whose collective goal can be summarized as minimizing the burden of injury in the population of British Columbia. This overarching goal must somehow be measurable and reportable. Appropriate data collection strategies and sources are required to support the production of metrics that accurately reflect the outcomes of activity in all domains of care relevant to the trauma system.  This work has evaluated the depth and scope of reporting on performance of British Columbia’s provincial systems of trauma care and injury management most recently available in the public domain using qualitative (descriptive) and semi-quantitative methods.  We identified 37 organizations in B.C. that produced public reporting relevant to the province’s system of trauma care and injury reporting as we have described it. While many of 42 these organizations were government or government-related, others were healthcare delivery organizations such as those of the regional health authorities, and other non-profit agencies.  It is notable that almost 60% of public reports relating to trauma and injury came from only two organizations; the B.C. Injury Research and Prevention Unit, and the B.C. Coroners Service. BCCS evaluates data on all mortality cases in the province and is focused on preventing death through the recommendation to government of helpful changes in regulation. The BCIRPU influences prevention efforts through research targeting the causes of injury, especially in children, and makes recommendations, although less directly, to government, health authorities and other agencies. There was a great deal of variation in the distribution of public reporting among the different domains of the provincial trauma system. For example, the pre-hospital EMS systems and the less described ‘system’ of post-acute recovery care and rehabilitation, which are considered fundamental domains of organized trauma care, produce minimal reporting. This is because pre-hospital services are provided by only two organizations, and rehabilitation and recovery services lack a designated agency, whereas prevention and acute care involve multiple agencies. However, there is no evidence that support reporting on one domain over another.  Currently, there are no performance measures reported in B.C. that collectively reflect all dimensions involved in reducing the burden of injury in the province’s population. Crude unadjusted mortality related to injury is commonly reported. Although it was often stratified by injury mechanism, patient risk-factors, or other demographic information, it was almost always unadjusted for injury severity and or health co-morbidity. This adjustment is crucial to any meaningful evaluation of process-related outcomes,  43 No common measures of injury burden such as potential years of life lost (PYLL), functional outcomes, employment status changes, quality of life measures (QALY/DALY), direct and indirect costs of care, or patient-reported outcomes such (satisfaction with services received) were publicly reported. This shortcoming likely relates to the fact that information-gathering that supports data collection and system evaluation is largely provider-driven and clinically focused. The capacity to make broader assessments of the outcomes of system performance is not yet integrated into system functions. The reporting of broader subsystem measures in each trauma system domain are important to understanding opportunities for improved system design and function. Disaster management, for example, is a pressing issue in B.C.’s trauma system; yet there are no specific measures communicating preparation for disaster. Similarly, there are no general measures that reflect the physical recovery of patients, let alone their psychological health or ability to engage in daily activities. Alberta Health Services have applied the whole system measures approach by constructing a balanced scorecard for provincial Addiction and Mental Health Services to reach the intended health care goals which are to improve quality, access, and sustainability of care delivery. The scorecard has focused on the six IOM quality dimensions (acceptability, accessibility, appropriateness, effectiveness, efficiency, and safety) (Alberta Health Services, 2010), which provide a performance framework to build 10 indicators that reflect the performance of the system as a whole.  The B.C. Ministry of health has adopted the IOM ‘Triple Aim’ goals of quality care, population health, and sustainable cost (Ministry of Health, 2015), which incorporate the six IOM Dimensions of Quality to establish system-level performance indicators to help reach overarching goals for the healthcare system 44 One important dimension of care is timely care in our trauma system which is partially measured (Figure 3.3, Appendix A). We were only able to locate data on emergency department waiting times (VCHA, 2013) and access to hospital beds from emergency (FHA, 2011). However, there are other aspects of systematized trauma care that must be measured. Access to specialized services, particularly for rural and remote populations as would be central to the well-functioning of a regionally integrated trauma system, are not captured in any timeliness measures that could be identified in this review. Wait time for elective and some urgent surgery were reported in some health system documents, but these are not relevant to the performance of the trauma system.  Some examples of timeliness measures relevant to whole system performance would be time of transport to definitive hospital care, delays to transfer of patients to in-patent rehabilitation facilities, and the time to full recovery of daily activities of injured patients. Although the importance of timely service in trauma is largely invalidated, timeliness seems an obvious driver of both improved patient outcomes and maximized system efficiency.  Patient centered care is a fundamental dimension in trauma care that is measured by both patient experience and satisfaction with the care experience. The B.C. Ministry of Health and the five health authorities have conducted surveys of patient experience in acute care (Ministry of Health, 2008; VCH, 2008). However, the surveys only cover the acute care in hospitals. More surveys must be conducted regularly to cover all domains of trauma care. Without measuring all domains of trauma care, it is not possible to effectively measure the priority goal of delivering patient-centered care to the population of B.C. (Ministry of Health, 2015). Also, setting targets for these measures and a clear plan of how to proceed if the targets are not met should be considered.  45 Safety is a vital dimension of trauma care. Safe care involves avoiding injury or harm to patients resulting from professional care (IOM, 2001). The minimization of adverse events and complications of care is a priority activity of modern healthcare delivery systems and the focus of extensive data collection and analysis around processes of clinical care. Metrics arising from these data, however, are not commonly reported in the public domain in general, and not at all for trauma or injury specifically that could be identified.  With regards to workforce health and well-being, WorkSafe B.C. annually reports on the rate of work related injuries that measures the safety of work places in B.C. However, this measure is not specific to trauma care (Appendix A). All the work-related injury measures we identified were based on claims received, which could constitute some measure of the safety of providers in our trauma system. While it seems unlikely that this information could easily be stratified to reflect the trauma/injury workforce, the possibility is interesting and would serve a WSM approach to system evaluation. Measures reflecting the rate of adverse events related to trauma care are necessary to help establish mechanisms that prevent these incidences from occurring. Examples of metrics capturing adverse events in trauma care are rates of nosocomial infection, missed diagnoses, and readmission to hospital or intensive care.  Improving the effectiveness of injury care in B.C. is a prime goal for decision makers (Ministry of Health, 2015). The overall performance of B.C.’s trauma system is captured partially in the publicly reported measures we identified. We found that few publicly reported measures specifically reflect on the high-level performance of a regionally integrated system of trauma care and injury control. Certainly, there was little evidence of alignment of this system 46 with the more general overarching goals reflected in organizational health system objectives prioritized by government health authorities, and other key agencies.  Crude mortality was frequently reported across several domains and for a variety of strata in the population. More precisely, crude mortality was reported according to injury mechanism (motor vehicle collisions, fall, suicides, etc.) and demography (age, sex, ethnicity, geography). As stated in the B.C. Government’s guiding framework for public health, age-standardized mortality rate (ASMR) is a preferred provincial health system performance measure, as is hospitalization rate. While these metrics are important, without adjustment for injury or comorbidity, and stratification for risk, they offer little means to guide system-wide performance improvement measures. Such adjustment would be critical to generate useful metrics from data to guide the planning of interventions in system design at the care and population management levels.  Per capita health care cost related to injury (SmartRisk, 2008), is the only publicly reported performance measure we found that reflects the efficiency dimension of trauma care at the whole system level. This measure, however, was generated in a national one-time report not directly reflective of the provincial systems of care and injury control. While it could be a difficult metric to target design changes to given methodological challenges in calculating the measure in a valid, reliable and timely way, this is one of the few measures we encountered that introduces a cost domain to injury burden measurement. Injury burden reduction was an important performance goal of Trauma Services B.C. Therefore, this measure may be useful if built into the performance measurement framework of the trauma system.  47 Injury prevention is a fundamental domain of trauma care which generated a majority of public domain reporting, but mostly on an ad hoc basis and not in a systematic way that could be seen to target directly the government’s priority measures of mortality and hospitalization. More measures that reflect the efficiency of each trauma domain likely need to be established.  According to the B.C. Ministry of Health, ensuring access to trauma services in B.C.’s rural and remote areas is an important in providing equitable trauma care. This is of particular concern due to the province’s resource-based industrial employment and transportation related injuries (Ministry of Health, 2015). Assuring equitable trauma care is especially challenging when considering B.C.’s large geographical size and diverse population. According the Institute for Health Improvement, equitable performance, measures are made by stratifying the system-level measures we have according to age, gender, race, township, region, sex and other demographic or socioeconomic descriptors (Martin, Nelson, Lloyd, & Nolan, 2007). 4.1 How to improve whole system level reporting Once we define the trauma system and the priorities intended for it, we can move to the next steps in modifying our performance measurement system. These steps include aligning decision makers’ goals for the trauma system with organizational goals that are usually at a smaller level, and then involving operative performance reporting and organization management in a regular communication with decision makers to set a common ground in what to measure and how to measure it. Ministry of Health would ideally lead this effort since it set the highest priorities for decision making in the provincial health care system.  Next is to acquire a clear strategic goal with measurable indicators for each domain of the trauma system. There will need to be infrastructure building, procedure development and 48 education around information management at all levels (providers to coders) to ensure that valid data is being collected reliably and efficiently. Thereafter, it would be essential to establish practical performance measures at the system level (but linked at the domain level) and test these for validity and reliability as drivers of process improvement that augments preferred outcomes (Kaplan, Norton, 1996; Liker, 2004). 4.2 Build a system level performance measure  A system level performance measure may be a summation of more than subsystem level measures. Performance measures have to reflect a process that has room of quality improvement. Therefore, in order to construct a system level measure, it is necessary to implement measures that reflect a balance between the structure, process and outcome. Also, these measures may be neither condition specific nor disease specific. Instead, it has to be put in a simple way for the decision makers to follow. The ultimate goal is to gather system-level measures that reflect all dimensions of system function in the way that quality of patient care (one domain of an injury care and control system) is currently evaluated using a framework of based on timeliness, safety, effectiveness, cost-efficiency, patient-centeredness, and equitability (Martin, Nelson, Lloyd, & Nolan, 2007). 4.3 Conclusion  Due to the magnitude of population-level injury burden and the cost and complexity of health management systems, there should be great interest by decision makers in actionably measuring performance of B.C.’s trauma care and injury control system as a whole. Currently, public reporting in B.C. does not reflect a whole system measures approach. In large measure, this is due to the absence of an operational construct that consolidates the well-described concept of a trauma system into a readily specialized the population-level health system responsive to 49 design changes based on performance measurement. Even at the domain or sub-system-level, performance measures linked to overarching performance priorities appear missing. A shift of focus from clinical process performance measures to system-level outcome measures is required.  4.4 Study limitations  a. Our study has examined publicly available reports from different organizations involved in trauma care and injury control across different settings and time periods. This limited our ability to examine the reports equally as government and organizational performance objectives would likely have been evolved over time as the health care system was developed in response to perceived needs. Also, different organizations have different goals for the trauma system, which makes it difficult for us to extract data needed for our study.  b. We did not include unpublished reports even though we recognize that there would be a great deal of internal operational reporting within organizations to drive lower-level or microsystem performance goals. We assumed that overarching system goals should, in large measure, be reflected in public domain reporting. Public accountability through such reporting is widely expected of all public agencies as per the Office of the Auditor General of B.C.  c.  Another limitations of this research is that retrieved reports were intended for a variety of audiences; and not necessarily for decision makers. This made the reports inconsistent in terms of emphasis and the metrics used to convey information to the public.    50 5 Summary Trauma care and injury control to serve a large geographically defined population such as that of British Columbia is complex and requires the functional integration of many agencies and organizations aligned strategically and operationally with the priorities of funders and decision makers at the level of government and health authorities. In terms of inputs and outputs, the activity of the system is challenging to describe and harder to measure. Moreover, the core processes that can be designed, changed and implemented to improve performance such that preferred outcomes are accomplished are themselves difficult to identify, describe and measure. There are a large number of organizations involved and most are accountable for myriad aspects of health and societal management, not just trauma care and injury control. By attempting to define the system, its performance objectives and appropriate measures by which to gauge performance, this work stands to clarify important challenges that are in the interest of system decision makers and designers to address.  The mandate of trauma system is to reduce burden of injury. Nowadays, the trauma system is perceived as a single body, which calls for a measurement framework that reflects the whole system. The Institute for Health Improvement has proposed a measurement framework that is based on the idea that health care systems can learn from systems in place for industry and that the health care performance should be measurable as a whole. The absence of an existing management framework for systems of trauma care and injury control beyond those well developed for trauma centers and, more recently, regional trauma systems, is an important challenge. Those work may imply that provincial data collection and reporting efforts require a shift in focus from a clinically based approach to one that would capture more system-relevant data as 51 well, This shift should be engineered with the oversight of decision makers so that the prime performance goals of the system, including but extending beyond patient care, are clearly embedded and measurable. Fulfilling all of the data gaps across trauma care continuum will take an intensive effort and time by all stakeholders and health care providers; however, the potential benefits for not just patients and health care personnel, but also the population at large are enormous. Creating and operationalizing a whole system measurement framework will be vital input for overseers of the current system of trauma care and injury control in British Columbia. 52 References Alberta Health Service, Addiction and Mental Health. (2010). 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British Columbia Injury Research and Prevention Unit. Retrieved on Sep 22, 2013 from http://www.injuryresearch.bc.ca/wp- content/uploads/2013/05/Injury-and-Physical-Activity-FINAL-Report-May24131.pdf Provincial Health Services Authority. Sports and recreation injury prevention strategies: Systematic review and best practices executive summary. British Columbia Injury Research and Prevention Unit. (n.d). Retrieved on Sep 22, 2013 from http://www.injuryresearch.bc.ca/reports-classifications/violence/ SmartRisk. (2008). The economic Burden of injury in Canada: Preventing injury with smart thinking. Retrieved on Sep 22, 2013 from http://www.parachutecanada.org/downloads/research/reports/EBI2009-Eng-Final.pdf 82 Treasury Board Secretariat. (2008). Performance reporting principles and guidelines.  Manitoba Finance. Retrieved on Sep 22, 2013   from https://www.gov.mb.ca/finance/tb/pdf/performance_reporting_guide.pdf US Department of Health and Human Services. (2006). Model trauma system planning and evaluation. US Department of Health and Human Services, Washington, DC. Retrieved  on Sep 22, 2013 Vital Statistics. (2012). Quarterly Digest, Volume 22 - Number 2. Retrieved on Sep 22, 2013  from http://www.gov.bc.ca/gov/content/vital-statistics/statistics reports/quarterly digests/2012-volume-22-number- Wolfe, A. (2001). Institute of Medicine Report: Crossing the Quality Chasm: A New Health Care System for the 21st Century. Policy, Politics, & Nursing Practice, 233-235   83 Appendices Appendix A: Compendium of performance measures identified in reports surveyed Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Injury rate  Crashes (rate / total) Office of the PHO - Public Health Approach to Alcohol Policy: an Updated Report from the Provincial Health Officer, 2008 Yes (Triple Aim, PHSA) Crush reduction Ministry of Transportation and Infrastructure - Annual report, 2013 Yes (Triple Aim, PHSA) Falls (rate) FHA - Health Profile, 2012 Yes (Triple Aim, PHSA) Homicide (rate / total / number / percentage) BCIRPU - Violence and Abuse in British Columbia, 2007 Yes (Triple Aim, PHSA) Injury (rate) Worksafe BC - Preventing Injuries to Hotel Workers, 1998 NO Injury by BC children’s hospital (rate / number / total) BCIRU - Unintentional Injuries in British Columbia: Trends and Patterns Among Children & Youth, 2005 Yes (Triple Aim, PHSA) Injuries (rate / number) Worksafe BC - Young Worker Focus Report, 2011 (+/-) (Triple Aim, PHSA) Injuries (rate) MOJ - Annual Service Plan Report, 2012 Yes (Triple Aim, PHSA) Injuries (rate) MOJ - Annual Service Plan Report, 2013 Yes (Triple Aim, PHSA) Injury (rate / number) Worksafe - 2012 Annual Report and 2013-2015 Service Plan, 2013 (+/-) (Triple Aim, PHSA) Injury (rate / number) Worksafe - Worksafe BC Statistics 2011, 2011 (+/-) (Triple Aim, PHSA) Injury occurrence - age standardized (rate) BCIRPU - VIHA Baseline Report on Injuries 2006, 2006 Yes (Triple Aim, PHSA) Injury occurrence (rate) BCIRPU - VIHA Baseline Report on Injuries 2006, 2006 Yes (Triple Aim, PHSA) Intimate partner violence (IPV) (total / average / rate) BCCS - Intimate Partner Violence in British Columbia, 2003-2011, 2012 Yes (Triple Aim, PHSA) 84 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Medical incidents (Rate) Vancouver Fire and Rescue Services - Vancouver Fire and Rescue Services Annual Report 2011, 2011 Yes (Triple Aim, PHSA) MVC (number / percentage / rate) Road Safety Unit, Ministry of Public Safety and Solicitor General - The Fraser Valley Integrated Road Safety Unit: An Evaluation, 2009 Yes (Triple Aim, PHSA) MVC (rate) MOH - Following the Evidence: Preventing Harms in Substance Use in BC, 2006 Yes (Triple Aim, PHSA) MVC (number / rate) Vancouver Police Department - Beyond the Call VPD Annual Report 2011, 2011 Yes (Triple Aim, PHSA) MVC injuries (total) BCIRPU - Motor Vehicle Crashes Among Young Drivers: Systematic Review & Recommendations for BC, 2005 Yes (Triple Aim, PHSA) MVC injury (rate) MOJ - BC Road Safety Enhanced Traffic Enforcement 2011 Annual Report, 2012 Yes (Triple Aim, PHSA) MVI (average / number / rate) Stats Canada - Motor vehicle accident deaths, 1979 to 2004, 2008 Yes (Triple Aim, PHSA) MVI (number / percentage) NHA - CrossRoads Report 2009: ―Fitness to Drive‖, 2009 Yes (Triple Aim, PHSA) Organized and non-organized injury (percentage / average) BCRIPU - Organized vs. Non-organized Sports-related Injuries: A Five Year Analysis from BC’s Children’s Hospital Emergency Department Data, 2008 Yes (Triple Aim, PHSA) Serious incidents (number) Office of the Ombudsman - The Best of Care – Getting it Right for Seniors (Part 2) Volume 1, 2012 Yes (Triple Aim, PHSA) Total domestic violence homicides in B.C. (total) BCCS - Findings and Recommendations of the Domestic Violence Death Review Panel, 2010 Yes (Triple Aim, PHSA) Total homicides in B.C. between (total) BCCS - Findings and Recommendations of the Domestic Violence Death Review Panel, 2010 Yes (Triple Aim, PHSA) Traffic injury (rate) Ministry of Public Safety and Solicitor General - Annual report, 2011 Yes (Triple Aim, PHSA) Unintentional injury (rate / number / total) BCIRU - Baseline Report On Injuries 2006, 2006 Yes (Triple Aim, PHSA) 85 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Unintentional injury (rate / number / total) BCIRU/NHA - Baseline Report on Injuries 2005, 2005 Yes (Triple Aim, PHSA) Violent crimes (number / rate) Vancouver Police Department - Beyond the Call VPD Annual Report 2011, 2011 Yes (Triple Aim, PHSA) Violent crimes reported (rate / total / number / percentage) BCIRPU - Violence and Abuse in British Columbia, 2007 Yes (Triple Aim, PHSA) Work injury (rate) Vancouver Fire and Rescue Services - Vancouver Fire and Rescue Services Annual Report 2011, 2011 NO Work injury (total / rate) Worksafe - Worksafe BC Statistics 2011, 2011 (+/-) (Triple Aim, PHSA) Mortality Accidental deaths (total) BCCS - BC Coroners Service 2010 Annual Report, 2013 (+/-) (Triple Aim, PHSA) Accidental drowning deaths (total / average / percentage) BCCS - Accidental Drowning Deaths 2008-2012, 2013 Yes (Triple Aim, PHSA) Accidental motorcycle deaths (rate / percentage) BCCS - Motorcyclist Deaths, 2007-2012, 2007-2012 Yes (Triple Aim, PHSA) All-terrain vehicle fatalities (total / average) BCCS - All-Terrain Vehicle Fatalities 2006-2011, 2012 Yes (Triple Aim, PHSA) ASMR  MOH - Model Core Program Paper: Prevention of Unintentional Injury, 2007 Yes (Triple Aim, PHSA) ASMR  Vital stat - Annual Report: Selected Statistics and Health Status indicators, 2011 Yes (Triple Aim, PHSA) Avalanche deaths (total) BCCS - Avalanche Deaths 1996-2013, 2013 Yes (Triple Aim, PHSA) Causes of death (Number) BCRIPU - Injury Prevention Indicators for Inuit Children and Youth, 2010 Yes (Triple Aim, PHSA) Child drowning deaths (total / percentage) BCCS - Child Death Review Unit Report on Drowning, 2007 Yes (Triple Aim, PHSA) Child deaths (total) BCCS - BC Coroners Service 2010 Annual Report, 2013 Yes (Triple Aim, PHSA) 86 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Crude death (rate / number) Vital stat - Annual Report: Selected Statistics and Health Status indicators, 2011 (+/-) (Triple Aim, PHSA) Crude mortality (percentage) BCIRPU - VCH Regional Trauma Annual Report, 2009-2010 Yes (VCH, Triple Aim, PHSA) Death (rate / number) Vital stat - Annual Report: Selected Statistics and Health Status indicators, 2011 Yes (Triple Aim, PHSA) Death (rate / number) Vital stat - Annual Report: Selected Statistics and Health Status indicators, 2011 Yes (Triple Aim, PHSA) Death by province (number / mean) NTR - annual report, 2012 Yes (Triple Aim, PHSA) Deaths (average / rate) BCCS - Child Drowning Deaths 2006-2012 (YTD), 2012 Yes (Triple Aim, PHSA) Deaths (average / rate) BCCS - MDMA (Ecstasy) Related Deaths 2006-2012, 2011 Yes (Triple Aim, PHSA) Deaths (number / rate / total) BCCS - 2009 Annual Report, 2009 Yes (Triple Aim, PHSA) Deaths (rate / number) BCIRPU - Falls and Related Injuries in Residential Care: A Framework and Toolkit for Prevention, 2011 Yes (Triple Aim, PHSA) Deaths (rate / percentage / number) BCIRUP - Primary Prevention of Physical Violence and Abuse in British Columbia, 2008 Yes (Triple Aim, PHSA) Deaths (rate / number / percentage) MOH - The Evolution of Seniors' Fall Prevention in BC, 2006 Yes (Triple Aim, PHSA) Deaths (rate / number / total) BCIRU - Baseline Report On Injuries 2006, 2006 Yes (Triple Aim, PHSA) Deaths (rate / number / total) BCIRU/NHA - Baseline Report on Injuries 2005, 2005 Yes (Triple Aim, PHSA) Deaths (rate / total) Office of the PHO - Public Health Approach to Alcohol Policy: an Updated Report from the Provincial Health Officer, 2008 Yes (Triple Aim, PHSA) Deaths (total / rate) BCCS - BC Coroners Service 2010 Annual Report, 2013 Yes (Triple Aim, PHSA) Deaths (rate / percentage) Office of the PHO - Special Report 2004: Prevention of Falls and Injuries Among the Elderly, 2004 Yes (Triple Aim, PHSA) Deaths of homeless individuals (total) BCCS - Deaths Among Homeless Individuals, 2007-2011, 2012 Yes (Triple Aim, PHSA) 87 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Driver motor vehicle fatalities (total) BCCS - BC interior motor vehicle incident fatalities, 2010 Yes (Triple Aim, PHSA) Fatalities (rate / number) Worksafe - 2012 Annual Report and 2013-2015 Service Plan, 2013 Yes (Triple Aim, PHSA) Fatalities (rate / number) Worksafe - Worksafe BC Statistics 2011, 2011 Yes (Triple Aim, PHSA) Fatalities (rate) MOJ - Annual Service Plan Report, 2012 Yes (Triple Aim, PHSA) Fatalities (rate) MOJ - Annual Service Plan Report, 2013 Yes (Triple Aim, PHSA) Forestry-related deaths (total) BCCS - Statistics 2002-2006 Forestry-Related Deaths, 2002-2006 Yes (Triple Aim, PHSA) Hospital standardized mortality ratio VCHA - VCHA Our Health Care Report Card 2013, 2013 Yes (VCH, Triple Aim, PHSA) Illicit drug deaths (rate / total) BCCS - BC Coroners Service 2010 Annual Report, 2013 Yes (Triple Aim, PHSA) Illicit drug overdose deaths (total / percentage) BCCS - Illicit Drug Overdose Deaths 2004-2011, 2012 Yes (Triple Aim, PHSA) Impaired driving fatalities (rate) MOJ - Annual Service Plan Report, 2012 Yes (Triple Aim, PHSA) Impaired driving fatalities (rate) MOJ - Annual Service Plan Report, 2013 Yes (Triple Aim, PHSA) Injury and fatality of non-speeding drivers in unsafe speed collisions (percentage) BCIRPU - Motor Vehicle Crashes Among Young Drivers: Systematic Review & Recommendations for BC, 2005 Yes (Triple Aim, PHSA) Injury and fatality of speeding drivers in unsafe speed collisions (percentage) BCIRPU - Motor Vehicle Crashes Among Young Drivers: Systematic Review & Recommendations for BC, 2005 Yes (PHSA, Triple Aim) Injury mortality (rate) BCIRPU - VCH Regional Trauma Annual Report, 2009-2010 Yes (VCH, Triple Aim, PHSA) Injury mortality (rates) BCIRPU - VCH Regional Trauma Annual Report, 2009-2010 Yes (VCH, Triple Aim, PHSA) Injury mortality (proportion) BCIRPU - VIHA Baseline Report on Injuries 2006, 2006 Yes (Triple Aim, PHSA) 88 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Injury mortality (rate) BCIRPU - VIHA Baseline Report on Injuries 2006, 2006 Yes (Triple Aim, PHSA) Injury mortality - age standardized (rate) BCIRPU - VIHA Baseline Report on Injuries 2006, 2006 Yes (Triple Aim, PHSA) Inmates deaths (total / average) BCCS - Deaths of Inmates of Correctional Facilities in British Columbia, 2004-2011, 2011 (+/-) (Triple Aim, PHSA) Inquests deaths (total) BCCS - BC Coroners Service 2010 Annual Report, 2013 (+/-) (Triple Aim, PHSA) Mortality (average / rate / time trend / number) BCRIU - BC Injury Atlas Injuries in British Columbia 2006-2010, 2012 Yes (Triple Aim, PHSA) Mortality (rate) FHA - Annual Population Health Report: Partnerships to Health, 2010 Yes (Triple Aim, PHSA) Mortality (rate / number / total) BCIRU - Baseline Report On Injuries 2006, 2006 Yes (Triple Aim, PHSA) Mortality (rate / number / total) BCIRU - Unintentional Injuries in British Columbia: Trends and Patterns Among Children & Youth, 2005 Yes (Triple Aim, PHSA) Mortality (rate / number / total) BCIRU/NHA - Baseline Report on Injuries 2005, 2005 Yes (Triple Aim, PHSA) Mortality (rate / number) BCIRU - Poisonings in British Columbia 2000-2005, 2009 Yes (Triple Aim, PHSA) Mortality (rate / percentage / number) BCIRUP - Primary Prevention of Physical Violence and Abuse in British Columbia, 2008 Yes (Triple Aim, PHSA) Mortality (rate / percentage) Office of the PHO - Special Report 2010: Investing in Prevention: Improving Health and Creating Sustainability, 2010 Yes (Triple Aim, PHSA) Mortality (rate / total / number / percentage) BCIRPU - Children and Youth in British Columbia: Injury by ages and stages 2003-2007, 2010 Yes (Triple Aim, PHSA) Mortality (rate / number) Vital stat - Annual Report: Selected Statistics and Health Status indicators, 2011 Yes (Triple Aim, PHSA) Mortality (rate) Office of PHO - The Health and Well-Being of the Aboriginal Population in BC Interim Update, 2012 Yes (Triple Aim, PHSA) Mortality (rate) Office of PHO - The Health and Well-Being of the Aboriginal Population in BC Interim Update, 2012 Yes (Triple Aim, PHSA) 89 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Mortality (rate / percentage) Office of the PHO - Special Report 2004: Prevention of Falls and Injuries Among the Elderly, 2004 Yes (Triple Aim, PHSA) Mortality (rate / total) NHA - Where are the Men? Chief Medical Health Officer's Report on the Health and Well-Being of Men and Boys in Northern BC, 2011 Yes (Triple Aim, PHSA) Motor vehicle fatalities (total / percentage) BCCS - BC interior motor vehicle incident fatalities, 2010 Yes (Triple Aim, PHSA) Motor vehicle fatalities (total / percentage) BCCS - BC Coroners Service 2010 Annual Report, 2013 Yes (Triple Aim, PHSA) Motor vehicle Incident Deaths (total / average) BCCS - Motor Vehicle Incident Deaths 2002-2011, 2012 Yes (Triple Aim, PHSA) Motorcycle deaths (total / percentage) BCCS - BC Coroners Service 2010 Annual Report, 2013 Yes (Triple Aim, PHSA) Motorcycle deaths in BC (rate) BCCS - Death Review Panel - Motorcycle Fatalities, 2012 Yes (Triple Aim, PHSA) Motorcycle mortality (Rate / number / total) BCIRU - Motor Vehicle-Related Injuries in British Columbia, 2007 Yes (Triple Aim, PHSA) MVC fatalities (number) NHA - Where are the Men? Chief Medical Health Officer's Report on the Health and Well-Being of Men and Boys in Northern BC, 2011 Yes (Triple Aim, PHSA) MVC fatalities (percentage) BCRIPU - Motor Vehicle Crashes And Occupant Restraint Use Among Aboriginal Populations In BC, 2008 Yes (Triple Aim, PHSA) MVC fatalities (total) BCIRPU - Motor Vehicle Crashes Among Young Drivers: Systematic Review & Recommendations for BC, 2005 Yes (Triple Aim, PHSA) MVC mortality (rate / number / total) BCIRU - Motor Vehicle-Related Injuries in British Columbia, 2007 Yes (Triple Aim, PHSA) MVC mortality (rate) FHA - Health Profile, 2012 Yes (Triple Aim, PHSA) MVI deaths  BC RCMP - 2012 BC RCMP Year in Review, 2012 Yes (Triple Aim, PHSA) MVI mortality (rate) BCIRPU - VCH Regional Trauma Annual Report, 2009-2010 Yes (VCH, Triple Aim, PHSA) 90 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Passenger motor vehicle fatalities (total) BCCS - BC interior motor vehicle incident fatalities, 2010 Yes (Triple Aim, PHSA) Pedestrian deaths (total / average) BCCS - Motor Vehicle Incidents: Pedestrian Deaths 2007-2011, 2012 Yes (Triple Aim, PHSA) Pedestrian fatalities (total / average) BCCS - Analysis of Pedestrian Deaths 2009-2012 (YTD), 2012 Yes (Triple Aim, PHSA) Pedestrian mortality (rate / number / total) BCIRU - Motor Vehicle-Related Injuries in British Columbia, 2007 Yes (Triple Aim, PHSA) Premature deaths (count) BCIRPU - VIHA Baseline Report on Injuries 2006, 2006 Yes (Triple Aim, PHSA) Premature death (rate / number) Vital stat - Annual Report: Selected Statistics and Health Status indicators, 2011 Yes (Triple Aim, PHSA) Preschool child deaths (total) BCCS - Swimming Pool Deaths (YTD), 2012 Yes (Triple Aim, PHSA) Ranking of cause of death (name of cause) BCIRPU - Motor Vehicle Crashes Among Young Drivers: Systematic Review & Recommendations for BC, 2005 Yes (Triple Aim, PHSA) Residential structure fire deaths (total / average / rate) BCCS - Residential Structure Fire Deaths in B.C., 2007-2011, 2011 Yes (Triple Aim, PHSA) Skiing and snowboarding deaths (total) BCCS - Skiing and Snowboarding Deaths 2000-2011, 2012 Yes (Triple Aim, PHSA) Standardized mortality ratio (SMR) BCIRPU - VIHA Baseline Report on Injuries 2006, 2006 Yes (Triple Aim, PHSA) Suicide (rate) BCRIPU - Injury Prevention Indicators for Inuit Children and Youth, 2010 Yes (Triple Aim, PHSA) Suicide (rate) Office of PHO - The Health and Well-Being of the Aboriginal Population in BC Interim Update, 2012 Yes (Triple Aim, PHSA) Suicide (rate) NHA - Where are the Men? Chief Medical Health Officer's Report on the Health and Well-Being of Men and Boys in Northern BC, 2011 Yes (Triple Aim, PHSA) Suicide (rate) FHA - Health Profile, 2012 Yes (Triple Aim, PHSA) Suicide (rate / total) BCCS - BC Coroners Service 2010 Annual Report, 2013 Yes (Triple Aim, PHSA) 91 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Suicide deaths (total / average) BCCS - Suicide Deaths 2002-2011, 2012 Yes (Triple Aim, PHSA) Suicide deaths (rate) Office of the PHO - Special Report 2010: Growing Up in BC, 2010 Yes (Triple Aim, PHSA) Suicide (rate / total) BCCS child death review - BC Coroners Service Child Death Review Panel: A Review of Child and Youth Suicides 2008-2012, 2013 Yes (Triple Aim, PHSA) Suicide (rate / number) Vital stat - Annual Report: Selected Statistics and Health Status indicators, 2011 Yes (Triple Aim, PHSA) Top ten accidental death (total / percentage) BCCS - BC Coroners Service 2010 Annual Report, 2013 Yes (Triple Aim, PHSA) Total swimming pool deaths (total) BCCS - Swimming Pool Deaths (YTD), 2012 Yes (Triple Aim, PHSA) Traffic fatalities (rate) Ministry of Public Safety and Solicitor General - Annual report, 2011 Yes (Triple Aim, PHSA) Traffic-related mortality (total / rate) BCIRPU - Motor Vehicle Crashes Among Young Drivers: Yes (Triple Aim, PHSA)  Traffic-related mortality (total / rate) Systematic Review & Recommendations for BC, 2005 Yes (Triple Aim, PHSA) Vehicle speeds and pedestrian deaths (rate) Vancouver Area Network of Drug Users - "We're all Pedestrians": Final Report of the Downtown Eastside Pedestrian Safety Project, 2010 Yes (Triple Aim, PHSA) Length of stay Length of stay (average) BCIRPU - VCH Regional Trauma Annual Report, 2009-2010 Yes (VCH, Triple Aim, PHSA) Length of stay (average) BCIRPU - VCH Regional Trauma Annual Report, 2009-2010 Yes (VCH, Triple Aim, PHSA) Length of stay (average) BCIRPU - VCH Regional Trauma Annual Report, 2009-2010 Yes (VCH, Triple Aim, PHSA) Length of stay (average) BCIRPU - VCH Regional Trauma Annual Report, 2009-2010 Yes (VCH, Triple Aim, PHSA) LOS (mean average) NTR - annual report, 2012 Yes (Triple Aim, PHSA) LOS (mean average) NTR - annual report, 2012 Yes (Triple Aim, PHSA) 92 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  LOS (mean average) BCIRPU - The Effectiveness Of Intervention Strategies To Reduce Motor Vehicle Crashes Involving Older Drivers: Systematic Reviews And Meta-Analyses, 2008 Yes (Triple Aim, PHSA) LOS (mean average) BCIRPU - The Effectiveness Of Intervention Strategies To Reduce Motor Vehicle Crashes Involving Older Drivers: Systematic Reviews And Meta-Analyses, 2008 Yes (Triple Aim, PHSA) LOS (Number / percentage) IHA - Kelowna General Hospital Facility Profile, 2007 Yes (Triple Aim, PHSA) LOS (Number / percentage) IHA - Royal Inland Hospital Facility Profile, 2007 Yes (Triple Aim, PHSA) LOS (Number / percentage) IHA - Kelowna General Hospital Facility Profile, 2007 Yes (Triple Aim, PHSA) LOS (Number / percentage) IHA - Royal Inland Hospital Facility Profile, 2007 Yes (Triple Aim, PHSA) LOS (rate / number) BCIRPU - Falls and Related Injuries in Residential Care: A Framework and Toolkit for Prevention, 2011 Yes (Triple Aim, PHSA) LOS (rate / number) BCIRPU - Falls and Related Injuries in Residential Care: A Framework and Toolkit for Prevention, 2011 Yes (Triple Aim, PHSA) LOS (rate / number / percentage) MOH - The Evolution of Seniors' Fall Prevention in BC, 2006 Yes (Triple Aim, PHSA) LOS (rate / number / percentage) MOH - The Evolution of Seniors' Fall Prevention in BC, 2006 Yes (Triple Aim, PHSA) LOS (rate / percentage) Office of the PHO - Special Report 2004: Prevention of Falls and Injuries Among the Elderly, 2004 Yes (Triple Aim, PHSA) LOS (rate / percentage) Office of the PHO - Special Report 2004: Prevention of Falls and Injuries Among the Elderly, 2004 Yes (Triple Aim, PHSA) Morbidity Injury morbidity rate - age standardized (rate) BCIRPU - VIHA Baseline Report on Injuries 2006, 2006 Yes (Triple Aim, PHSA) Injury morbidity rate (rate) BCIRPU - VIHA Baseline Report on Injuries 2006, 2006 Yes (Triple Aim, PHSA) Morbidity (rate / number / total) BCIRU - Baseline Report On Injuries 2006, 2006 Yes (Triple Aim, PHSA) 93 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Morbidity (rate / number / total) BCIRU - Unintentional Injuries in British Columbia: Trends and Patterns Among Children & Youth, 2005 Yes (Triple Aim, PHSA) Morbidity (rate / number / total) BCIRU/NHA - Baseline Report on Injuries 2005, 2005 Yes (Triple Aim, PHSA) Standardized morbidity ratio (SMR)  BCIRPU - VIHA Baseline Report on Injuries 2006, 2006 Yes (Triple Aim, PHSA) Patients experience survey Access to care MOH - Patient Experiences with Acute Inpatient Hospital Care in BC, 2008 Yes (Triple Aim, PHSA) Access to care FHA - SURVY OF ACUTE PATIENTS EXPIREINCE, 2008 Yes (Triple Aim, PHSA) Continuity and transition MOH - Patient Experiences with Acute Inpatient Hospital Care in BC, 2008 Yes (Triple Aim, PHSA) Continuity and transition FHA - SURVY OF ACUTE PATIENTS EXPIREINCE, 2008 Yes (Triple Aim, PHSA) Continuity of care items MOH - Patient Experiences with Acute Inpatient Hospital Care in BC, 2008 Yes (Triple Aim, PHSA) Information and education MOH - Patient Experiences with Acute Inpatient Hospital Care in BC, 2008 Yes (Triple Aim, PHSA) Information and education FHA - SURVY OF ACUTE PATIENTS EXPIREINCE, 2008 Yes (Triple Aim, PHSA) Involvement of family MOH - Patient Experiences with Acute Inpatient Hospital Care in BC, 2008 Yes (Triple Aim, PHSA) Involvement of family FHA - SURVY OF ACUTE PATIENTS EXPIREINCE, 2008 Yes (Triple Aim, PHSA) Personal injury or harm question MOH - Patient Experiences with Acute Inpatient Hospital Care in BC, 2008 Yes (Triple Aim, PHSA) Physical comfort MOH - Patient Experiences with Acute Inpatient Hospital Care in BC, 2008 Yes (Triple Aim, PHSA) Physical comfort FHA - SURVY OF ACUTE PATIENTS EXPIREINCE, 2008 Yes (Triple Aim, PHSA) Respect for patient preferences MOH - Patient Experiences with Acute Inpatient Hospital Care in BC, 2008 Yes (Triple Aim, PHSA) Respect for patient preferences FHA - SURVEY OF ACUTE PATIENTS EXPIREINCE, 2008 Yes (Triple Aim, PHSA) Staff wash hands question MOH - Patient Experiences with Acute Inpatient Hospital Care in BC, 2008 Yes (Triple Aim, PHSA) 94 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Hospitalization Distribution of MV injury hospitalization (total) BCIRPU - All Motor-Vehicle Injury and Off-Road Motor-Vehicle Injury Hospitalizations in BC, 2001/02-2008/09, 2012 Yes (Triple Aim, PHSA) Distribution of off-road MV injury hospitalization (total) BCIRPU - All Motor-Vehicle Injury and Off-Road Motor-Vehicle Injury Hospitalizations in BC, 2001/02-2008/09, 2012 Yes (Triple Aim, PHSA) Hospitalization adjusted (rate) MOH - Model Core Program Paper: Prevention of Unintentional Injury, 2007 Yes (Triple Aim, PHSA) Hospitalization (average / rate / time trend / number) BCRIU - BC Injury Atlas Injuries in British Columbia 2006-2010, 2012 Yes (Triple Aim, PHSA) Hospitalization (average / number) NTR - annual report, 2012 Yes (Triple Aim, PHSA) Hospitalization (rate) Office of the PHO - Special Report 2010: Growing Up in BC, 2010 Yes (Triple Aim, PHSA) Hospitalization (rate / total / number / percentage) BCIRPU - Children and Youth in British Columbia: Injury by ages and stages 2003-2007, 2010 Yes (Triple Aim, PHSA) Hospitalization (number / percentage) IHA - Kelowna General Hospital Facility Profile, 2007 Yes (Triple Aim, PHSA) Hospitalization (number / percentage) IHA - Royal Inland Hospital Facility Profile, 2007 Yes (Triple Aim, PHSA) Hospitalization (rate) Office of the PHO - Special Report 2010: Investing in Prevention: Improving Health and Creating Sustainability, 2010 Yes (Triple Aim, PHSA) Hospitalization (rate) BCIRPU - The Effectiveness Of Intervention Strategies To Reduce Motor Vehicle Crashes Involving Older Drivers: Systematic Reviews And Meta-Analyses, 2008 Yes (Triple Aim, PHSA) Hospitalization (rate / number / percentage) MOH - The Evolution of Seniors' Fall Prevention in BC, 2006 Yes (Triple Aim, PHSA) Hospitalization (rate / percentage) Office of the PHO - Special Report 2004: Prevention of Falls and Injuries Among the Elderly, 2004 Yes (Triple Aim, PHSA) 95 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Hospitalizations (rate / total) Office of the PHO - Public Health Approach to Alcohol Policy: an Updated Report from the Provincial Health Officer, 2008 Yes (Triple Aim, PHSA) Hospitalizations (rate / number) Stats Canada - Unintentional injury hospitalizations among children and youth in areas with a high percentage of Aboriginal identity residents, 2012 Yes (Triple Aim, PHSA) Hospitalizations (number) NHA - Where are the Men? Chief Medical Health Officer's Report on the Health and Well-Being of Men and Boys in Northern BC, 2011 Yes (Triple Aim, PHSA) Hospitalizations (percentage / number / rate) BCRIPU - WINTER SPORTS INJURIES, 2011 Yes (Triple Aim, PHSA) Hospitalizations (percentage / number / rate) BCRIPU - Injury Insight: Playground injuries in Children, 2012 Yes (Triple Aim, PHSA) Hospitalizations (rate) BCCDC - BC Harm Reduction Strategies and Services Committee Policy Indicators Report 2011, 2012 Yes (Triple Aim, PHSA) Hospitalizations (rate) BCCDC - BC Harm Reduction Strategies and Services Committee Policy Indicators Report 2011, 2011 Yes (Triple Aim, PHSA) Hospitalizations (rate) adjusted BCRIPU - Seniors' Falls Can be Prevented, 2007 Yes (Triple Aim, PHSA) Injury hospitalization (rate) CIHI - health indicators, 2012 Yes (Triple Aim, PHSA) Motorcycle hospitalization (rate / number / total) BCIRU - Motor Vehicle-Related Injuries in British Columbia, 2007 Yes (Triple Aim, PHSA) MVC hospitalization (rate / number / total) BCIRU - Motor Vehicle-Related Injuries in British Columbia, 2007 Yes (Triple Aim, PHSA) Number of all (MV) injury hospitalizations (total) BCIRPU - All Motor-Vehicle Injury and Off-Road Motor-Vehicle Injury Hospitalizations in BC, 2001/02-2008/09, 2012 Yes (Triple Aim, PHSA) Number of off-road injury hospitalizations (total) BCIRPU - All Motor-Vehicle Injury and Off-Road Motor-Vehicle Injury Hospitalizations in BC, 2001/02-2008/09, 2012 Yes (Triple Aim, PHSA) 96 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Pedestrian hospitalization (rate / number / total) BCIRU - Motor Vehicle-Related Injuries in British Columbia, 2007 Yes (Triple Aim, PHSA) Snowmobile injury hospitalizations (rate / total) BCIRPU - SNOWMOBILING INJURIES, 2012 Yes (Triple Aim, PHSA) Traffic-related hospitalization (total / rate) BCIRPU - Motor Vehicle Crashes Among Young Drivers: Systematic Review & Recommendations for BC, 2005 Yes (Triple Aim, PHSA) Cost Claims cost (total) ICBC - annual report, 2012 NO Coast of injury (number) BCIRPU - Children and Youth in British Columbia: Injury by ages and stages 2003-2007, 2010 Yes (Triple Aim, PHSA) Cost (number) Office of the PHO - Public Health Approach to Alcohol Policy: an Updated Report from the Provincial Health Officer, 2008 Yes (Triple Aim, PHSA) Cost (percentage) MOH - Framework for Core Functions in Public Health in BC, Resource Document, 2006 Yes (Triple Aim, PHSA) Cost (rate / number) Work safe - Worksafe BC Statistics 2011, 2011 NO Cost (rate / number) BCIRPU - The Effectiveness Of Intervention Strategies To Reduce Motor Vehicle Crashes Involving Older Drivers: Systematic Reviews And Meta-Analyses, 2008 Yes (Triple Aim, PHSA) Cost (total) BCRIPU - Seniors' Falls Can be Prevented, 2007 Yes (Triple Aim, PHSA) Cost (total) NHA - Annual Report, 2011 Yes (Triple Aim, PHSA) Cost (total) Vancouver Area Network of Drug Users - "We're all Pedestrians": Final Report of the Downtown Eastside Pedestrian Safety Project, 2010 Yes (Triple Aim, PHSA) Cost (total) Worksafe - 2012 Annual Report and 2013-2015 Service Plan, 2013 (+/-) (Triple Aim, PHSA) Cost (total) BCAS - Annual Report: Helping Save Lives, 2011 Yes (BCAS,Triple Aim, PHSA) 97 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Cost (number) Road Safety Unit, Ministry of Public Safety and Solicitor General - The Fraser Valley Integrated Road Safety Unit: An Evaluation, 2009 (+/-) (Triple Aim, PHSA) Cost (number) Office of the PHO - Special Report 2010: Investing in Prevention: Improving Health and Creating Sustainability, 2010 Yes (Triple Aim, PHSA) Cost (total) MOJ - Annual Service Plan Report, 2012 Yes (Triple Aim, PHSA) Cost (total) MOJ - Annual Service Plan Report, 2013 Yes (Triple Aim, PHSA) Cost per weighted case VCHA - VCHA Our Health Care Report Card 2013, 2013 Yes (VCH, Triple Aim, PHSA) Cost (total) Smartrisk - Economic Burden of Unintentional Injury in British Columbia, 2001 Yes (VCH, Triple Aim, PHSA) Timely Access to hospital bed from emergency (percentage) FHA - SERVICE PLAN, 2011 Yes (Triple Aim, PHSA) ER wait time (min) VCHA - VCHA Our Health Care Report Card 2013, 2013 Yes (VCH, Triple Aim, PHSA) Hospital separation # Hospital separations (count) BCIRPU - VIHA Baseline Report on Injuries 2006, 2006 Yes (Triple Aim, PHSA) Hospital separation (rate) BCIRPU - VCH Regional Trauma Annual Report, 2009-2010 Yes (VCH, Triple Aim, PHSA) Hospital separation (rate / number / total) BCIRU - Baseline Report On Injuries 2006, 2006 Yes (Triple Aim, PHSA) Hospital separation (rate / number / total) BCIRU - Unintentional Injuries in British Columbia: Trends and Patterns Among Children & Youth, 2005 Yes (Triple Aim, PHSA) Hospital separation (rate / number / total) BCIRU/NHA - Baseline Report on Injuries 2005, 2005 Yes (Triple Aim, PHSA) Hospital separation (rate) BCIRPU - VIHA Baseline Report on Injuries 2006, 2006 Yes (Triple Aim, PHSA) Hospital separation (rate / number) BCIRU - Poisonings in British Columbia 2000-2005, 2009 Yes (Triple Aim, PHSA) 98 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Hospital separation (rate / total / number / percentage) BCIRPU - Violence and Abuse in British Columbia, 2007 Yes (Triple Aim, PHSA) Hospital separation - age standardized (rate) BCIRPU - VIHA Baseline Report on Injuries 2006, 2006 Yes (Triple Aim, PHSA) Hospital separations (rate / percentage / number) BCIRUP - Primary Prevention of Physical Violence and Abuse in British Columbia, 2008 Yes (Triple Aim, PHSA) Hospital transfer  Transfers (percentage) BCAS - Annual Report: Helping Save Lives, 2011 Yes (BCAS, PHSA, Triple Aim) Patient transfers into VCH (percentage) BCIRPU - VCH Regional Trauma Annual Report, 2009-2010 Yes (VCH, Triple Aim, PHSA) Claims  Claims (rate / number) Worksafe - Worksafe BC Statistics 2011, 2011 (+/-) (Triple Aim, PHSA) Claims (rate / number) Worksafe - 2012 Annual Report and 2013-2015 Service Plan, 2013 (+/-) (Triple Aim, PHSA) Claims (rate / number) Worksafe - Worksafe BC Statistics 2011, 2011 (+/-) (Triple Aim, PHSA) Claims cost (total) ICBC - annual report, 2012 (+/-) (Triple Aim, PHSA) Claims injury (rate) ICBC - annual report, 2012 (+/-) (Triple Aim, PHSA) Disability claim (number) Worksafe BC - Preventing Injuries to Hotel Workers, 1998 Yes (Triple Aim, PHSA) Duration (rate / number) Worksafe - Worksafe BC Statistics 2011, 2011 (+/-) (Triple Aim, PHSA) Fatal claims (number) Worksafe BC - Preventing Injuries to Hotel Workers, 1998 (+/-) (Triple Aim, PHSA) Tele claim (rate / number) Worksafe - Worksafe BC Statistics 2011, 2011 (+/-) (Triple Aim, PHSA) Workers experience (rate / number) Worksafe - 2012 Annual Report and 2013-2015 Service Plan, 2013 (+/-) (Triple Aim, PHSA) Workers experience (rate / number) Worksafe - Worksafe BC Statistics 2011, 2011 (+/-) (Triple Aim, PHSA) 99 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Hospital visits ED visits (number) Provincial Emergency Services Project - Progress Report, 2003 Yes (Triple Aim, PHSA) ED visits (number / percentage) IHA - Kelowna General Hospital Facility Profile, 2007 Yes (Triple Aim, PHSA) ED visits (number / percentage) IHA - Royal Inland Hospital Facility Profile, 2007 Yes (Triple Aim, PHSA) ED visits (rate / number / total) BCIRU - Unintentional Injuries in British Columbia: Trends and Patterns Among Children & Youth, 2005 Yes (Triple Aim, PHSA) ED visits (rate / percentage) Office of the PHO - Special Report 2004: Prevention of Falls and Injuries Among the Elderly, 2004 Yes (Triple Aim, PHSA) ED visits (rate / total / number / percentage) BCIRPU - Violence and Abuse in British Columbia, 2007 Yes (Triple Aim, PHSA) ED visits (percentage / number) BCRIPU - WINTER SPORTS INJURIES, 2011 Yes (Triple Aim, PHSA) ED visits (percentage / number) BCRIPU - Injury Insight: Playground injuries in Children, 2012 Yes (Triple Aim, PHSA) Injury visits (number) BCRIPU - Organized vs. Non-organized Sports-related Injuries: A Five Year Analysis from BC’s Children’s Hospital Emergency Department Data, 2008 Yes (Triple Aim, PHSA) Potential years of life lost due to injury  PYLL (PYLL-75) (average) BCIRPU - VIHA Baseline Report on Injuries 2006, 2006 Yes (Triple Aim, PHSA) PYLL (PYLL-75) (average) BCIRPU - VIHA Baseline Report on Injuries 2006, 2006 Yes (Triple Aim, PHSA) PYLL (rate / number) Vital stat - Annual Report: Selected Statistics and Health Status indicators, 2011 Yes (Triple Aim, PHSA) Disability-adjusted life years DALY (rate / percentage) Office of the PHO - Special Report 2010: Investing in Prevention: Improving Health and Creating Sustainability, 2010 Yes (Triple Aim, PHSA) DALY (percentage) MOH - Framework for Core Functions in Public Health in BC, Resource Document, 2005 Yes (Triple Aim, PHSA) 100 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Others  Alternate level of care days VCHA - VCHA Our Health Care Report Card 2013, 2013 Yes (VCH, Triple Aim, PHSA) Ambulatory care sensitive condition rate (100000) VCHA - VCHA Our Health Care Report Card 2013, 2013 Yes (VCH, Triple Aim, PHSA) Burden of injury BCIRPU - Sports and Recreation Injury Prevention Strategies: Systematic Review and Best Practices EXECUTIVE SUMMARY, 2001 Yes (Triple Aim, PHSA) Event volume (percentage) BCAS - Annual Report: Helping Save Lives, 2011 (+/-) (Triple Aim, PHSA) Hospital readmission (rate) CIHI - health indicators, 2012 Yes (Triple Aim, PHSA) Impaired driving in Canada (average / rate / number) Stats Canada - (Impaired Driving in Canada), 2013 Yes (Triple Aim, PHSA) Inspection Vancouver Fire and Rescue Services - Vancouver Fire and Rescue Services Annual Report 2011, 2011 (+/-) (Triple Aim, PHSA) Leading cause of injury BCRIPU - Seniors' Falls Can be Prevented, 2007 Yes (Triple Aim, PHSA) Leading risk factors contributing to the MVC (percentage) BCRIPU - Motor Vehicle Crashes And Occupant Restraint Use Among Aboriginal Populations In BC, 2008 Yes (Triple Aim, PHSA) Leading sport types of injuries (list) BCRIPU - Organized vs. Non-organized Sports-related Injuries: A Five Year Analysis from BC’s Children’s Hospital Emergency Department Data, 2008 Yes (Triple Aim, PHSA) Number of surgeries (total) HSPO - BC Health Services Purchasing Organization, 2013 Yes (Triple Aim, PHSA) Pre-hospital events (percentage) BCAS - Annual Report: Helping Save Lives, 2011 Yes (BCAS, Triple Aim, PHSA) Recommendation distribution (percentage / total) BCCS - BC Coroners Service 2010 Annual Report, 2013 Yes (Triple Aim, PHSA) Research Productivity VCHA - VCHA Our Health Care Report Card 2013, 2013 Yes (VCH, Triple Aim, PHSA) 101 Specific metric Name of organization and report (Yes/+or-/No) Alignment with priorities (which organization priority)  Response statistics (number) Vancouver Fire and Rescue Services - Vancouver Fire and Rescue Services Annual Report 2011, 2011 Yes (VCH, Triple Aim, PHSA) Staff safety scores VCHA - VCHA Our Health Care Report Card 2013, 2013 Yes (VCH, Triple Aim, PHSA) Vital event statistics (number) Vital stat - Quarterly Digest, Volume 22 - Number 2, 2012 Yes (Triple Aim, PHSA)  102 Appendix B: Inventory of surveyed reports Name of organization  Type of report  Name of report (year published) British Columbia Injury Research and Prevention Unit  Injury insight  Helmets for Winter Sports (January, 2013) SNOWMOBILING INJURIES (January, 2013) Playground injuries in Children (June, 2012) WINTER SPORTS INJURIES (December, 2011) Systemic review  Sports and Recreation Injury Prevention Strategies: Systematic Review and Best Practice (2001) Injury Prevention Intervention Strategies Among Aboriginal People: A Systematic Review (April, 2007) The Effectiveness Of Intervention Strategies To Reduce Motor Vehicle Crashes Involving Older Drivers: Systematic Reviews And Meta-Analyses (March, 2008) Statistical reports  Injury Prevention Indicators for Inuit Children and Youth (November, 2010) Baseline Report On Injuries 2006 Baseline Report on Injuries 2005 Too Hot for Tots! Evaluation of a Pediatric Burns Prevention Resource (November, 2011) Poisonings in British Columbia 2000-2005 (April, 2009) Organized vs. Non-organized Sports-related Injuries: A Five Year Analysis from BC’s Children’s Hospital Emergency Department Data (January, 2008) BC Injury Atlas Injuries in British Columbia 2006-2010 (September, 2012) Violence and Abuse in British Columbia (march, 2007) Children and Youth in British Columbia: Injury by ages and stages 2003-2007 (November, 2010) Developing Injury Prevention Indicators for First Nations Children & Youth in Canada (November, 2010) Unintentional Injuries in British Columbia: Trends and Patterns Among Children & Youth (2005) Evidence review  The Injury Consequences of Promoting Physical Activity (April, 2013) Bullying, Suicide, and Self-Harm Among Individuals Who Are Overweight (March, 2013) Primary Prevention of Physical Violence and Abuse in British Columbia (July, 2008) Evidence Review of Unintentional Injury Prevention (2007) 103 Name of organization  Type of report  Name of report (year published) Others  Motor Vehicle Crashes among Young Drivers: Systematic Review and Recommendations for BC (November, 2005) Motor Vehicle Crashes And Occupant Restraint Use Among Aboriginal Populations In BC (April, 2008) Motor Vehicle-Related Injuries in British Columbia (2007) All Motor Vehicle Injury and Offroad Motor Vehicle Injury Hospitalizations in BC, 2001/02 – 2008/09 (March, 2012) Falls and Related Injuries in Residential Care: A Framework and Toolkit for Prevention Seniors' Falls Can be Prevented       National Trauma Registry Annual report National Trauma Registry Annual Report 2013       Centre for Addictions Research of BC Evidence review Following the Evidence: Preventing Harms in Substance Use in BC       Clinical Prevention Policy Review Committee Final report A Lifetime of Prevention: The Report of the Clinical Prevention Policy Review Committee (2009, December)       First Nations Health Council Health plan British Columbia Tripartite First Nations Health Plan (November, 2006) The Transformative Change Accord: First Nations Health Plan (2005)       Fraser Basin Council Ad hoc Identifying Health Concerns Relating to Oil and Gas Development in Northeastern BC - human Health Risk Assessment Phase I Report       Fraser Health Authority Annual report Survey of Acute Care Patient Experience -2008 SERVICE PLAN FHA (2011) Regional Profile (2010) Health Profile (2012) Interim FNHA Annual Report -2010 Annual Population Health Report: Partnerships to Health (2012) 104 Name of organization  Type of report  Name of report (year published)       Insurance Corporation of British Columbia Annual report Revised Service Plan 2013 – 2015 (2013) Annual Report (2013) Statements and Schedules of Financial Information (2013       Interior Health Authority Facility profile Kelowna General Hospital Facility Profile (2007) Royal Inland Hospital Facility Profile (2007) Review report  Fraser Health Congestion Review Report (April, 2012) Annual report  2012/13-2014/15 Service Plan (2012) Regional Profile (2010) Health Assessment and Disease Surveillance Performance Improvement Plan (2011) Health Inequities in British Columbia (2013) President and CEO Report to the Board (2013)       Justice Institute of British Columbia Annual report Strategic Plan 2010–2015 (2011) Financial Statements of Justice Institute of British Columbia (2013) Annual Report (2012)       Medical Health Officer A preliminary report  Population Health and Oil and Gas Activities: A Preliminary Assessment of the Situation in North Eastern BC (2007)       Ministry of Community, Sport and Cultural Development Annual report Revised 2013/14 – 2015/16 Service Plan (2013) 2012-13 Annual Service Plan Report (2013)       Ministry of Health of British Columbia Survey  Acute Care Patient Experiences in BC Survey -2008 Annual report  Revised 2013/14 – 2015/16 Service Plan -2013 2013-2016 Annual Service Plan (2013) Annual Service Plan Report 2011-2012 -2012 Others  The Evolution of Seniors' Fall Prevention in BC (2006) Model Core Program Paper: Prevention of Unintentional Injury (2007) 2009/10 Report on Health Authority Service Plans (2010) 105 Name of organization  Type of report  Name of report (year published) Improving Care for BC Seniors: An Action Plan (2012) Access to Surgery in BC: The Cutting Edge - Conference Report (2009) Framework for Core Functions in Public Health in BC, Resource Document (2005)       Ministry of Justice Annual report Service Plan 2013-2016 (2013) 2011-2012 Annual Service Plan Report -2012 2012/13 Annual Service Plan Report -2013       Ministry of Justice, British Columbia Coroners Service Death review  Four Fatal Aviation Accidents Involving Air Taxi Operations on British Columbia’s Coast (2012) Child Drowning Deaths 2006-2012 (YTD) -2012 MDMA (Ecstasy) Related Deaths 2006-2012 (2013) Motorcyclist Deaths 2007-2012 (2013) Findings and Recommendations of the Domestic Violence (2010) Statistics 2002-2006 Forestry-Related Deaths  Swimming Pool Deaths (YTD) (2012) All-Terrain Vehicle Fatalities 2006-2011 (2012) B.C. Interior Motor Vehicle Incident Fatalities 2010 (2012) Skiing and Snowboarding Deaths 2000-2011 (2012) Illicit Drug Overdose Deaths 2004-2011 (2012) Avalanche Deaths 1996-2013 (2013) Deaths Among Homeless Individuals, 2007-2013 (2013) Motor Vehicle Incident Deaths 2002-2011 (2012) Motor Vehicle Incidents: Pedestrian Deaths 2007-2011 -2012 Motorcycle Fatalities (2010) Suicide Deaths 2002-2011 (2012) Accidental Drowning Deaths 2008-2012 (2013) Deaths of Inmates of Correctional Facilities in British Columbia, 2004-2011 (2011) Analysis of Pedestrian Deaths 2009-2012 (YTD) (2013) Findings and Recommendations of a Death Review Panel Convened To Examine Three 2008 Workplace Incidents Involving Tree Fallers (2009) 106 Name of organization  Type of report  Name of report (year published) Residential Structure Fire Deaths in B.C., 2007-2011 (2013) Intimate Partner Violence in British Columbia, 2003-2011 -2012 Child Death Review Unit Report on Drowning (2007) Findings and Recommendations of a Death Review Panel Convened To Examine Winter 2008-2009 Avalanche Related Deaths Involving Snowmobile Operators (2009) BC Coroners Service Child Death Review Panel: A Review of Child and Youth Suicides 2008-2012 (2013) Annual report 2009 Annual Report (2010) BC Coroners Service 2010 Annual Report (2013) Other Coroner's Report into the death of Nodar Kumaritashvili (2010)       Ministry of Justice, Police Service Division Annual report Strategic Plan 2012-2017 Enhanced Traffic Enforcement Program (2013) Road safety BC Road Safety Enhanced Traffic Enforcement 2011 Annual Report (2012) Crime Statistics in British Columbia, 2012 (2013) Other Police Resources in British Columbia, 2011 (2013)       Ministry of Public Safety and Solicitor General Annual report Annual Service Plan Report 2010-11 -2011 Road safety unite The Fraser Valley Integrated Road Safety Unit: An Evaluation (2009) Victim Services and Crime Prevention Division Activity Report 2009-2010 (2010)       Ministry of Transportation and Infrastructure Annual report Revised 2013/14 – 2015/16 Service Plan -2013 2012/13 Annual Service Plan Report (2013)       Northern Health Authority Strategic report Strategic Plan 2009-2015 (2009) Annual report 2012-2013 Annual Report (2013) NHA Annual Report 2010-2011 (2011) Survey Survey of Acute Care Patient Experience -2008 107 Name of organization  Type of report  Name of report (year published) other Regional Profile (2010) Northwest Surgical Services Review (2010) Aboriginal Health Services Plan (2007) Men's Health Matters because Men Matter: Community Consultation on Men's Health: What We Heard (2011) Where are the Men? Chief Medical Health Officer's Report on the Health and Well-Being of Men and Boys in Northern BC (2011)       Office of Provincial Health Officer Annual report The Health and Well-Being of Women in BC (2008) The Health and Well-Being of the Aboriginal Population in BC Interim Update (2012) Special report Investing in Prevention: Improving Health and Creating Sustainability (2010) Prevention of Falls and Injuries Among the Elderly (2004) Growing Up in BC (2010) Others  An Ounce of Prevention: A Public Health Rationale for the School as a Setting for Health Promotion (2003) Public Health Approach to Alcohol Policy: an Updated Report from the Provincial Health Officer (2008) Health and Well-being of Children in Care in BC: Report 1 on Health Services Utilization and Mortality (2006)       Office of the Ombudsperson   The Best of Care – Getting it Right for Seniors (Part 2) Volume 1 (2012)       Provincial Emergency Services Project   Progress Report (2003)       Provincial Health Services Authority Survey Survey of Acute Care Patient Experience -2008 Annual report 2010-11 Annual Progress Update: Core Public Health Programs (2012) Service Plan (2011) Strategic Plan 2010-2013 (2010) Regional Profile (2010) other Taking a Second Look: Analyzing Health Inequities in BC with a Sex, Gender, and Diversity Lens (2009) 108 Name of organization  Type of report  Name of report (year published) Steps Forward 2009 A Progress Report On How PhSA, Supported By The Provincial Government, Is Improving Specialized Health Services For British Columbians (2009) Gap Analysis and Improvement Plan: Unintentional Injury Prevention Core Public Health Program (2009) 2010 - 11 Gap Analysis & Improvement Plan: Healthy Community Environments Core Public Health Program (2011) Safe Start Program Final Report (2012)       Road Health Coalition   CrossRoads Report 2009: ―Fitness to Drive‖ (2009)       Royal Canadian Mounted Police in British Columba Annual report 2012 BC RCMP Year in Review (2012) LMD Annual Report       Smartrisk Statistical report Economic Burden of Unintentional Injury in British Columbia (2001)       Statistics Canada Injury report Motor vehicle accident deaths, 1979 to 2004 (2008) Impaired Driving in Canada 2011 (2012) Unintentional injury hospitalizations among children and youth in areas with a high percentage of Aboriginal identity residents (2012) Work Injuries (2007) A Profile of Disability in Canada, 2001       Urban Health Research Initiative   Findings from the evaluation of Vancouver’s Pilot Medically Supervised Safer Injecting Facility – Insite (2009)       Vancouver Area Network of Drug Users   "We're all Pedestrians": Final Report of the Downtown Eastside Pedestrian Safety Project (2010)       Vancouver Coastal Health Survey Survey of Acute Care Patient Experience -2008 Annual report 2013/14 – 2015/16 Service Plan (2013) Regional Profile (2010) Quality and Safety First Annual Report (2011) 109 Name of organization  Type of report  Name of report (year published) Other Regional Trauma Annual Report 2009-2010 (2010) VCHA Our Health Care Report Card 2013 (2013)       Vancouver Fire and Rescue Services Annual report Strategic Plan 2011-2015 (2012) Vancouver Fire and Rescue Services Annual Report (2011)        Vancouver Island Health Authority Survey Acute Care Patient Experience Results -2008 Annual report 2013/14-2015/16 Service Plan (2013) Regional Profile (2010) Vancouver Island Health Authority (VIHA) Five-Year Strategic Plan 2008-2013 (2009)       Vancouver Police Department   Beyond the Call VPD Annual Report (2011)       Vital Statistics Statistical report Quarterly Digest, Volume 22 - Number 2 -2012 Annual Report: Selected Statistics and Health Status indicators (2011)       Worksafe British Columbia Annual report Annual Report and 2013-2015 Service Plan (2013) Statistical report Preventing Injuries to Hotel Workers (1998) Young Worker Focus Report (2011) WorkSafe BC Statistics (2011)    110 Appendix C: Data abstraction tool   

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