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Quality Improvement

Frequently Asked Questions

Health Quality Ontario sends each hospital CEO their customized report via email. To make sure you receive your report, please add to your safe sender list.

Physicians and other leaders involved in perioperative care, such as the Chiefs of Surgery and Anesthesiology, as well as other members of the Medical Advisory Committee and leaders in Quality Improvement and Decision Support may be interested in the information contained in the report.

The first Hospital Performance Series Report focuses on Choosing Wisely Canada indicators. This report provides hospitals with data on their own performance compared to other Ontario hospitals in the use of pre-operative electrocardiography (ECG) and chest radiography (X-ray) for low-risk surgery groups including: endoscopy procedure, ophthalmologic surgery, and other low-risk surgeries. This indicator set was chosen as a priority by the hospital sector.

An Excel data table including the crude rates for all indicators for all Ontario hospitals is sent to hospital CEOs via email.

It is not mandatory to include these indicators in your Quality Improvement Plan. However, if your organization has identified, through a review of the data in the report, that the reduction of routine pre-operative tests for patients undergoing low-risk surgeries is an area of improvement for your organization, you are welcome to include these as custom indicators in your plan.

The report was last updated in November 2017 with data from fiscal year 2016/17. Currently, there are no plans to refresh the report. We apologize for the inconvenience. If you have any questions, please contact

Although no validated comprehensive “low-risk” surgical procedure list exists, the selection of low-risk surgeries in the report are consistent with the broad definition of “low-risk procedures” outlined in existing research1 and guidelines on pre-operative cardiac evaluation.2,3 The majority of the procedures are minimally invasive and are performed in outpatient settings. Some examples of these low-risk procedures include hip/knee arthroscopy and hernia repair. For a complete list of surgical procedure codes, please refer to the Technical Appendix available online at

This report focuses on Ontario patients aged 18 and older who underwent elective low-risk surgeries, including endoscopy, ophthalmologic surgery or other low-risk surgeries in either outpatient day surgery or acute in-patient settings.

The data sources used in the report include the Canadian Institute for Health Information (CIHI) Discharge Abstract Database (DAD) and CIHI National Ambulatory Care Reporting System (NACRS), Ontario Health Insurance Plan (OHIP) Claims History Database (i.e. OHIP physician service claims) and the Registered Persons Database (RPDB). Data is provided by the Institute for Clinical Evaluative Sciences (ICES).

For the purposes of this report, ECG or chest X-ray tests occurring within 60 days before the surgical procedure were considered as pre-operative tests. It is possible that some tests during this time were ordered for reasons not associated with the planned low-risk surgery. However, this period is generally accepted by hospitals for pre-operative evaluation and has been used in previous studies.1, 2, 4 For more information about the indicators, please refer to the Technical Appendix available online at

Your hospital should not aim for a rate of zero for these tests. For some patients, these tests are necessary and the patient may benefit from the valuable clinical data that they provide. Although the appropriateness and optimal rate of pre-operative testing cannot be set by using administrative data due to data availability and limitations, substantial institution-level variation indicates opportunities for standardization and quality improvement in this area.

In a recent study, it was found that where the procedure took place was a bigger driver of pre-operative testing before low-risk procedures than most clinical patient characteristics1. While older age, procedure type, concurrent pre-operative consultation and the institution at which the procedure was conducted are major drivers of pre-operative tests, patient comorbidities are only minor drivers.1

Crude rates are reported. The purpose of this report is to provide you with your hospital’s performance data and help drive your hospital quality improvement efforts. Crude rates will make it easier to track how your quality improvement efforts are influencing your performance over time.

Small cell sizes (between 1 and 5 observations) are supressed in order to adhere to the privacy policy set out by the Institute for Clinical Evaluative Sciences (the data provider). This is done to prevent residual disclosure of individuals. Throughout the report, the symbol “†” was used to denote suppressions for your hospital. If your hospital did not perform any of the selected low-risk surgical procedures during the reporting period, the symbol “§” was used.

A step-by-step approach to improvement is listed in the Quality Improvement Change Ideas section featured in the report. This section follows a quality improvement approach and references examples of toolkits developed to improve overall perioperative services and screening. These resources align with the Choosing Wisely Canada campaign.

The change ideas featured in the report were developed through a rigorous process of literature review, environmental scan, consultation, focus groups with health care professionals, and expert panel review. A team of quality improvement specialists and clinical experts worked together to develop and refine the change ideas to create a step-by-step approach to improvement.

Health Quality Ontario has hosted a number of webinars to bring together peer hospitals to share approaches and experiences for making improvements to pre-operative testing processes. We will continue to support these connections via webinars and conferences. If you are interested in these webinars and other supports, please email us at

You can access the Technical Appendix that provides a more detailed report methodology and important data interpretation notes by visiting You can also email us at


1 Kirkham KR, Wijeysundera DN, Pendrith C, Ng R, Tu JV, Laupacis A, et al. Preoperative testing before low-risk surgical procedures. CMAJ. 2015; 187(11): E349–E358. 2 Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol. 2007 Oct 23; 50(17): e159-242. 3 Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B. et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014; 64(22): e77-e137. 4 Bugar JM, Ghali WA, Lemaire JB, Quan H. Canadian Perioperative Research Network. Utilization of a preoperative assessment clinic in a tertiary care centre. Clin Invest Med 2002; 25: 11-8.

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