copy of performance measure kebidanan
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Performance Measures-OBGYN
J F M A M J J A S O N
1 Primery Scsetelah gagal dalam proses lahir normal
2 Primery SC pada fetal disters3 lahir normal setelah SC
4 Kegagalan melahirkan normal setelah SC
5 The delivery of an infant by planned repeat Cesarian Section eighing 25!! grams"
# The delivery of an infant by planned repeat $nd%ction of labor eighing 25!! grams"
& 'clampsia
( The in)hospital initiation of antibiotics 24ho%rs or more after term vaginal delivery"
* '+cessive ,aternal blood loss e+cept ith abr%ptio placenta-placenta previa as evidenced
by either a red cell transf%sion. a hematocrit less than 22 or a hemoglobin less than &
or a decrease in hematocrit of more than 11 or of hemoglobin more than 3"5
* / ,aternal length of stay more than 2 days after 0aginal elivery
1! / ,aternal length of stay more than 3 days after Cesarian Section
11 / ,aternal readmission ithin 14 days of delivery
12 / ,aternal death %p to and incl%ding 42 days post part%m"
13 eaths of infants-fet%s eighing 5!! grams or more. s%b)categorised by in)hospital
neonatal deaths. pre)part%m stillborns and intr)part%m stillborns"
14 The delviery of an infant eighing less than 1(!! grmas in a hospital itho%t a $C
15 The transfer of a neonate to a $C at another hospital"
1# /n apgar score of 4 or less at 5 min%tes in live born infants ho eigh more than
1!!! grams and less than 25!! grams"
1& The diagnosis of a massive aspiration syndrome
1( The diagnosis of a birth tra%ma s%bd%ral and cerebral hemorrhage. fract%res.in%ries to nerves. spinal cord. r%pt%re of organs6
1* /n infant eighing more than and e7%al to 25!! grams. having a clinically apparent sei8%re
prior to discharge from the delivery hospital. or apgar score of 4 at 5 min%tes or re7%ires
admission to the $C for more than 24 ho%rs
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Performance Measures - Department of Medicine
1 ,ortality 9evie2 Transfer to another ac%te facility
3 se of Cons%ltant for Chronic stable condition"
4 ,ore than 3 Cons%ltants
5 :ail%re to call Cons%ltant hen diagnosis is not knon or patient is not responding"
# nplanned transfer to Special Care nit
& Code ;l%e 'val%ation
( o Code
*
Chronic ?eart :ail%re
Pne%monia
rinary Tract $nfection
Thrombolytic Therapy in patients ith ac%te ,$
12 evelopment of Pne%monia in patients treated in Special Care nit
evelopment of $nfections related to the %se of intra)vasc%lar devices in Special
Care nit and efinitive @bservation nit"
13 /ppropriateness of >
a" Colonoscopy
b" pper Aastrointestinal 'ndoscopy
c" 'ndoscopic 9etrograde Cholangiopancreatpgraphyd" ;ronchoscopy
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Performance Measures- Department of Surgery
1 o Specimen hen specimen is e+pected6
2 Significant discrepancey beteen pre)op and pathological diagnosis3 o gross and-or microscopic diagnosis hen s%ch is e+pected"
4 :ails approved medical necessity criteria for invasive proced%re hether or not the
removal of a specimen as the intent of the proced%re"
5 Cancellation of s%rgery after ind%ction"
# nplanned hospital admission from o%tpatient s%rgery %nit"
& Transfer to another ac%te care facility
( @peration for removal of foreign body left in operative site"
*
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23 Post)operative symptoms only6 at discharge
& Temperat%re 1!! oral6 1!1 rectal6 degrees farenheight ithin 24 ho%rs prior discharge"
( :ebrile ie> 1!3degrees :arenheight)oral6 at leasst once daily for more than *# ho%rs
* ?ospital inc%rred adverse incident e+cept parental carelessness-inattention
1! Transfer to another facility
11 n%s%al ,edical iagnosis
12 nplanned admission of an o%tpatient"
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Medical ecord e!ie" Yes No
1 is the final diagnosis recorded on the face sheet in f%ll. itho%t %se of
abbreviations-symbols"
2 Completion of a history and physical ithin 24 ho%rs of admission"
3 Presence of c%rrent physical e+am in patients chart. prior to all s%rgery %nder
Aeneral or maor regional anesthesia. e+cept for emergency operations"
4 9ecording of pre)operative diagnosis before s%rgery
5 )
/de7%ate
$nade7%ate
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Performance Measures - &a'oratory ;enchmark
1 @rgani8ational performance $mprovements
J F M A M J J A S O Na E%ality Control problems are corrected ithin 24 ho%rs 1!!F
b Timeliness of res%lt reporting>
1 9es%lts of all :;S to be ready ithin 2 ho%rs 1!!F
2 9eference lab res%lts to be ready ithin 4( ho%rs !F
3 /ll stat lab ork reported ithin one ho%r from time
of lab receipt to time of phone report"
4 Panic val%es are do%ble checked and called"
5 Proficiency testing and training for Gpoint of careG lab
11 ,edication se
a Therape%tic dr%g eval%ation dras coincide appropriately
ith dr%g administration" 1!!F
111 S%rveillance. Prevention and Control of $nfections
a Aloves orn hen draing blood 1!!F
b Safety clothing orn hile handling specimens 1!!F
10 ,anagement of $nformation
a =aboratory re7%isitions completed properly 1!!F
0 Patients 9ights
a Patients confidentiality is maintained" 1!!F
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Performance Measures - Pat%ology
1 @rgani8ational Performance $mprovements
a Cases referred by pathologist for peer revie *5F
b /ppropriateness of specific lab tests
1 ;lood C%lt%res *5F
2 Stat Tests 1!!F
c /greement ith fro8en section vs permanent section 1!!F
d /%topsy res%lts agree ith clinical findings" 1!!F
11 Care of Patient
a ;lood ;ank sage
1 @rdering
a6 Total %nits of blood %sed
b6 Cross ,atch H2"5
c6 $ndications for %se 1!!F
d6 Patients receiving only one %nit trend
e6 Patients receiving over 5 %nits trend
2 /dministration
a6 Transf%sion 9eaction !F
b6 $nf%sion time over 4 ho%rs 1!!F
111 ,anagement of $nformation
a Pathology reports for malignancy ill incl%de>
1 ?istologic analysis
2 Arade of t%mo%r
3 '+tension of t%mo%r-margins-resection
4 =ymph node e+amined
5 =ymph node that contains evidence of metastatic disease
# Primary t%mo%r of breast. colon. l%ng ill be cancer staged"
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Performance Measures- adiology Medical (Benc%mar)s *++,
1 $mproving @rgani8ational Performance
a Peer 9evie J F M A M J J A S O N D
1 ,ammograms
2 Chests Iray in pediatrics
3 =%ng Scans
b Pne%mothora+ after invasive proced%res
11 /ssessment of Patients
a /ppropriateness of st%dies
1 ;ari%m 'nema )F of negative st%dies benchmarks 1!F62 ?$/ scans ) F of negative st%dies benchmarks 1!F 6
b 9adiology 9eport Confirmation
1 Positive radiology report vs cholecystectomy
2 'stmated fetal age vs gestational age at birth
3 Presence-absence of leiomyomata post %ltraso%nd report
4 eedle locali8ation for abnormal breast tiss%e confirmed
by pathology
c /ppropriate %se of non)ionic contrast
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Performance Measures - adiological Department Benc%mar)
1 @rgani8ational Performance $mprovement
a Canceled-9epeat proced%re J F M A M J J A S O N D
1 %e to poor preparation !F
2 Technical error !F
3 '7%ipment fail%re !F
b Complications
1 Perforations !F
2 ?ematomas !F
3 $nfectionsnosocomial6 !F
4 /spiration !F
c 9eect-repeat film rate analysis 1!F
d ,islabeled films and-or reports !F
e Timeliness of on)call Iray personnel
1 /nsered beeper ithin 15 min%tes 1!!F
2 $nto hospital ithin 3! min%tes of being called 1!!F
f @%tpatient
1 Se7%ences are correct 1!!F
2 :ormatted images are diagnostic 1!!F
h @%tpatient E%estionairre to be trended for improvements6
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Performance Measures - adiological Department (.
11 /ssessment of Patients
a Patients are screened for allergies ie> iodine. late+. medications6 1!!F
b @%tpatients re7%iring contrast media not screened for ?I
of C?:. 9enal :ail%re" !F
c 9eaction to contrast media re7%iring intervention" !F
111 ,anagement of the 'nvironment of Care
a :ilm badges orn at all times 1!!F
b 'nvironmental Safety Check 1!!Fc 9adiation Physicist e7%ipment check 1!!F
d =ead /pron check 1!!F
10 ,anagement of $nformation
a Proper completion of Iray 9e7%est
1 Clinical $nformation filled o%t on re7%est 1!!F
2 ate of '+amination 1!!F
3 '+am re7%ested matches reasson for Iray 1!!F
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Performance Measures - P%ysiot%erapy (Benc%mar)s of *++,
1 Planning and Providing Care
a /ppropriateness of doc%mentation
1 $nitial 'val%ation
2 Progress 9eport
a6 aily on inpatients
b6 'very to eeks on @%tpatients
3 ischarge S%mmary
b 'ffectiveness of transfer gait training provided to patients"
Progress as noted in>
1 =evel of need for assistance grad%ally red%ced or eliminated"
2 Time red%ction in time6 to move a distance
3 istance travelled
c 'ffectiveness of hirlpool TI to patients ith cell%litis-o%nd
1 'vidence of debridement
2 iminished selling
3 ecreased pain level
4 ecreased o%nd si8e
11 @rgani8ational Performance $mprovement
a Satisfaction
1 Patient
2 Physician
111 ,anagement of the 'nvironment of Care
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a 'nvironmental ro%nds
P%ysiot%erapy-/riteria for Documentation
1 $nitial 'val%ation
J F M A M J J A S O N Da S%bective :indings
b @bective :indings
c Short Term Aoals
d =ong Term Aoals
e Prior level of f%nctioning
f Patient-:amily $nvolvement
11 Progress otes>
a Completed daily inpatient6b Complete every to eeks o%tpatient6
c $ndicated treatment rendered
d :re7%ency of treatment
e =ocation
f /ny change in condition noted
g Patient-family %nderstanding of therapy
111 ischarge of S%mmary incl%des>
a Aoals met
b :%nctional stat%s %pon discharge
c ?ome Program
d ,echanism for :ollo)%p
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P%ysiot%erapy-0n!ironmental ounds
a Treatment /rea1 Treament area enclosed to g%arantee privacy to patient
2 o modality e7%ipment in c%bicle other than e7%ipment to be %sed
3 Clean linen for each patient
b 'lectrical Safety
1 se only e7%ipment ith three ire line cordsJ old e7%ipment
properly gro%nded"
2 /ll electrical connection tight
,an%al-a%to ad%stments in orking order
3 'lectrical e7%ipment inspected every # months
c
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4 Sterili8ed 7 month
5 Covered at all times
P%ysiot%erapy-0n!ironmental ounds
f ltraso%nd
1 nit gro%nded
2 /ll sitches off
3 Transd%cer and pl%g connections tight and clean
g 'lectrical Stim%lator
1 /ll ire and pl%g connections tight
2 Controls off before and after %se
3 'lectrodes in good condition
h Transc%taneo%s 'lectrical erve Stim%lator
1 =ine Cord nits sho%ld be gro%nded
2 /ll electrodes ashed and alloed to dry
3 ;atteries recharged"
i $ntermittent Traction
1 nit gro%nded
2 ials at 8ero
3 ?ead halters. straps. cables. halter fastenings sec%re
'7%ipment ,aintenance
1 9eg%lar periodic e7%ipment checks performed ith doc%mentation
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Performance Measures-Food Ser!ices(*
1 %tritional Care
a 'val%ation of 7%ality and appropraiteness of n%tritional caregiven to patients on t%be feeding"
J F M A M J J A S O N D
1
1
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Performance Measures-Food Ser!ices(.
d 'val%ation of appropriatness of diet order to iagnosis
1 id diet provide ade7%ate calories to meet the 9/D
2
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Performance Measures - P%armacy
1 Preparation and ispensing
a ispensing 'rrors1
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Medication 1se
1 Prescribing and @rdering
a /ntibiotic 9evie
1 /ppropriateness
2 Prophylactic %se
a6 $nitial dose not later than 1 ho%r prior to s%rgery
b6 :inal dose not less than 4( ho%rs after s%rgery
3 'mpiric se
4 se of restricted dr%gs
5 $nitiation of antibiotic 24 ho%rs post part%m
b /ppropriate %se and management of dr%gs
1 Thrombolytic agents
2 TP
3 Pitocin
4 'mergency epartment
c Prescribing Patterns
2 'ffects on Patients
a /dverse dr%g reactions
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Performance Measures - 2nfection /ontrol J F M A M J J A S O N
1 S%rveillance. Prevention and Control of $nfection
a /vailability of protective barrier as per standard preca%tions re7%irement"b $nfectio%s aste handling and disposal
c osocomial $nfections>
1 Patients on ventilator ho developed pne%monia
2 Post)operative pne%monia in patients e+periencing>
i6 Cholecystectomy
ii6 Splenectomy
iii6 /bdominal ;ypass graft
iv6 /bdominal perineal resection
v6 Colon resection
3 Primary bloodsream infection in patients ith>i6 Central line
ii6 mbilical line
4 evelopment of o%nd infections in GCleanG cases
11 'd%cation
Pengu)uran 3iner4a - Pengendalian 2nfe)si
1 S%rveillance. Pencegahan dan Pengendalian $nfeksi
a Ketersediaan penghalang pelind%ng ses%ai keb%t%han tindakan pencegahan standar"
b Penanganan limbah infeksi%s dan pemb%angan
c $nfeksi osokomial>
1 Pasien pada ventilator yang mengembangkan pne%monia
2 pne%monia pasca operasi pada pasien yang mengalami>
i6 Kolesistektomi
ii6 Splenektomi
iii6 per%t ;ypass graft
iv6 per%t reseksi perineal
v6 Colon reseksi
3 $nfeksi bloodsream primer pada pasien dengan>
i6 Central line
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ii6 line %mbilical
4 Pengembangan infeksi l%ka dalam kas%s GCleanG
a /ll clinical staff ill have inservice in infection control-standard preca%tion"
Sem%a staf klinis akan memiliki intern dalam pengendalian infeksi - tindakan pencegahan standar"
5uarterly 0!aluation of Standard Precautions$Body Su'stance 2solation
ate>
,ethodology> Conc%rrent st%dy of ?ealthcare / total of observations made in the department
9evieer>
Yes No Non-compliant
1 Aloves orn hen draing blood
2 Aloves orn hen handling blood and body fl%ids
3 Aloves changed bteen patientsD
4 ?ands ashed after gloves removedD
5 ,asks. goggles. gons readily availableD
# oes employee kno location of '7%ipmentD
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& ,asks. goggles orn if splattering possibleD
( sed needles not recapped and disposed of in proper containers
* /reas properly cleaned folloing contamination ith body fl%idD
'val%asi Tri%lan Standar ;ahan Keaspadaan - T%b%h $solasi
Tanggal >
,etodologi> St%di Conc%rrent Pekera Kesehatan
Tem%an> Sebanyak pengamatan yang dilak%kan di departemen
resensi b%k%>
1 Sar%ng tangan dipakai saat menggambar darah
2 Sar%ng tangan dipakai saat menangani darah dan cairan t%b%h
3 Sar%ng tangan ber%bah bteen pasienD
4 Tangan dic%ci setelah sar%ng tangan dilepasD
5 ,asker. kacamata. ga%n tersediaD
# /pakah karyaan mengetah%i lokasi '7%ipmentD
& ,asker. kacamata yang dikenakan ika m%ncrat m%ngkinD
( Bar%m bekas tidak recapped dan dib%ang dalam adah yang tepat
* /rea benar dibersihkan kontaminasi berik%t dengan cairan t%b%hD
Aoogle Teremahan %nt%k ;isnis>Perangkat PeneremahPeneremah Sit%s
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Performance Measures - Business Office
1 @rganisation Performance $mprovement
J F M A M J J A S O N D
a C%stomer Complaints !F
b 'rrors in Patient ;ills !F
c 'rror in $ns%rance-Corporate claims !F
d T%rn aro%nd time for patient discharge to billing over 3! days !F
Performance Measures - Materials Management
2 @rganisation Performance $mprovement
a S%pplies are available for filling departmental orders
b %mber of vendors for similar s%pplies are minimi8e for cost controlc Special s%pply re7%est are filled ithin time frame re7%ested
d @ld-o%tdated s%pplies in Store
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is)s Management Mont%ly Safety /ommittee eport
J F M A M J J A S O N D
1 a Patient $n%ry
b 'mployee $n%ry
c 0isitor $n%ry
d eedle Stick $n%ry
e Sec%rity 'lopement
f :al l /ttended
g '7%ipment :ail%re or ,alf%nction
h '7%ipment ser or ,alf%nction
i '7%ipment ser 'rror
tility :ail%re or ,alf%nction
k tility ser 'rror
l ,edical evice 9ecalls
o of /dmissions
/verage aily Cens%s
o of ischarges
Cedera pasien
Cedera karyaan
Cedera peng%n%ng
eedle Tongkat Cederakeamanan 'lopement
at%h ,enghadiri
Kegagalan peralatan ata% Ker%sakan
Peralatan Pengg%na ata% Ker%sakan
Kesalahan Peralatan Pengg%na
Kegagalan %tilitas ata% Ker%sakan
Kesalahan %tilitas Pengg%na
/lat Kesehatan Penarikan
idak ada Penerimaan
9ata)rata ?arian Sens%s
Tidak ada dari Pemb%angan
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11 'nvironment of Care
a $ncidents of needlestick $n%ry shall decrease by F
7%arterly
b 'mployee back in%ries shall decreasse by F 7%arterly
c /ll employees are inserviced ann%ally on>
16 :ire Safety
26 ?a8ardo%s ,aterials
36 ?a8ard detection S%rvey
46 $llness and $n%ry Protection Program
56 '+pos%re Control Program
#6 'mergency Preparedness Program&6 Sec%rity Program
nsiden Cedera ar%m akan men%r%nF
tri%lanan
Cedera p%ngg%ng Karyaan har%s decreasse olehF tri%lanan
Sem%a karyaan inserviced setiap tah%nnya pada>
16 :ire Safety
26 ;ahan ;erbahaya36 deteksi bahaya S%rvey
46 Penyakit dan Program Perlind%ngan Cedera
56 Program Pengendalian 'kspos%r
#6 Program Kesiapsiagaan ar%rat
&6 Program Keamanan
Performance Measures - 0ngineering Department Benc%mar)s of *++,
1 'nvironment of Care
a Patient-'mployee Safety
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F M A M J J A S O N D
16 isaster rills
26 :ire rills
36 'mergency Aenerator Proced%re
46 Policies-Proced%res c%rrent
56 Preventive ,aintenance Proced%res ithin 3! days c%rrent6
#6 epartment $nservice monthly
&6 :ire Sprinkler 0alves open e+cept d%ring service6
(6 ;io)med e7%ipment Checksc%rrent to month d%e date6
*6 9o%nd Checks perform ,onday to :riday6
1!6
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a Satisfaction E%estionnaire
b Patients Complaints
c Staff Complaints
11 'nvironment of Care
a /ll environmental service staff ill complete ann%al $nservice)
on $nfection Control and Safety"
b ?o%sekeeping $nspections
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Organi6ational Performance 2mpro!ement Board eport
Performance Measures Benc%mar)s /omments 57 * 57 . 57 8
1 0ol%mea %mber of $npatient discharges
1 Total n%mber if discharges
/verage length of stay @=@S6
2 Total n%mber of Corporate discharges
/verage length of stay @=@S6
3 Total n%mber of $ns%rance discharges
/verage length of stay @=@S6
b o day-o%tpatient s%rgeries
c o of 'mergency visits
d F @cc%pancy
11 ,ortality
a Total n%mber of deaths
1 F of deaths
b Perioperative mortality rate deaths ithin 4( ho%rs
of s%rgery or invasive proced%re6
c eborn ,ortality 9ate
d ,aternal ,ortality 9ate
e o of patient deaths in 'mergency epartment
f F of deaths meeting criteria or e+pected %stifiedmortality"
g %mber of a%topsies performed"
111 ?ospital /c7%ired $nfection
a Total 9ate
b Clean s%rgical rate
c Post part%m infection rate
d eonatal $nfection 9ate
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10 9isk ,anagement
a o of claims involving patient in%ry-death
b o of claims involving hospital risk-loss
c o of ,edication 'rrors
d o of patient-visitor falls
0 Case ,anagement
a enial rate for private ins%red patients
b /ppeal s%ccess rate
c enial rate for Corporate patients
d /ppeal s%ccess rate
01 ,edication se
a o of dr%g reactions res%lting in prolonged
length of stay"
b o of dr%g reactions res%lting in temporary or
permanent patient in%ry and potential hospital
liability"
c o of cases revieed not meeting established
criteria"
011 ;lood sage
a o of transf%sion reactions res%lting in prolonged
length of stay"
b F of cases revieed not meeting established criteria
c Crossmatch-transf%sion ratio
d o of asted %nits
0111 S%rgery-$nvassive Proced%res
a nplanned ret%rns for s%rgery
b o of Complications
c o of tiss%e cases revieed
d o of meeting criteria
e o of non)tiss%e cases
f o of meeting criteria
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1I Cesarean Sections
a F of meeting criteria
b F of repeat proced%res
c F of primary proced%res
d F of 0aginal deliveries secondary to C)section
deliveries 0;/C6
I Codes
a F of s%ccessf%l codes performed in>
1 'mergency epartment
2 SC
3 ,edical-S%rgical
4 Pediatrics
5 @;
I1 Transfer to another ac%te care facility
a o of emergency patients transferredb o of inpatients transferred for services not
provided by the hospital
c F of transfers meeting transfer criteria"
I11 Special Care nit
a o of transfer from loer level of care in hospital to special
care %nit"
b o of patients admitted to special care %nits not
meeting admission or discharge criteria"
c o of patients ret%rned to special care %nit ithin4( ho%rs of discharge from %nit"
d o of patients that die ithin 4( ho%rs of discharge
from %nit"
I111 9eadmissions
a o of readmissions ithin 3! days from related or
similar diagnosis-treatment"
b F of cases meeting criteria for appropriateness
of first discharge and of readmission
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I10 /,/s
a o of 'mergency patients leaving /,/
b o of other patients leaving /,/
I0 Patient Complaintsa o of patient-family complaints involving patient
care
b o of patient-family complaints involving billing errors
or charges for services
c o of patient-family complaints involving a hospital
provided service or employee
d F of %nresolved complaints
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Performance Measures - 0mergency Department
1 /ssessment
a Aeneral oc%mentation-Triange 1!!F
11 Care of the Patient
a Standard of Care> 1!!F
1 ?ead $n%ry
2 Poisoning-@verdose
3 /bdominal pain)non)tra%matic
4 Shortness of breath
5 :ract%res-islocations-Sprains
# 'ye Complaints
& Tra%ma
( 0aginal ;leeding
* =aceration1! Sei8%re
11 Chest pain
12 Pediatrics
13 Pediatric :ever
b ,edication se !F
1 ,edication 'rror
111 Contin%%m of Care
a $nfection Control of nitb Standard Preca%tion
10 @rgani8ational Performance $mprovements
a Patient-physician complaints
b /,/
c =
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b @rientation to nit
c ,edication taken at home
d /llergies
e Special eeds
System 9evie)both s%bective and obective
a Aastrointestinal
b Cardiovasc%lar
c 9espiratory
d e%rological-'ndocrine
e ,%sc%loskeletal
f ,ental Stat%s
g ischarge Planning
2 Plan of Care
a Plan implemented on date of admission
b Plan individ%ali8ed on date of admission
c 'ach problem n%rsing diagnosis6 has o%tcome ith deadline
d Plan is %pdated timely evidenced by>
1 iscontin%ance of problems solved
2 e problems initiated ith date
3 @%tcome
e Charting on %rses notes are directly related to problems in
plan of care at least once in 24 ho%rs"
Nursing Performance Assessment (.
3 ,edication
a /re the reasons for P9 medications recordedDb ?as the effect of P9 medication been chartedD
c ,eds are charted ith the appropriate time. ro%te dose and site of inection
d ,/9 contains initials. f%ll signat%res. and title of administering n%rse"
e /re GomittedG or Gref%sedG medications charted properly on the medication
record and in the n%rses notesD
4 $ntake-@%tp%t
a $ntake-@%tp%t ere recorded each shift
b Totaled each 24 ho%rs"
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b Totaled each 24 ho%rs"
5 oc%mentation of $0 Care
a 9eflects site checked each shift
b Signs of infiltration-phlebitits doc%mented ith follo)%pc Site-si8e and type of needle %sed to start $0 Chart
d $0 T%bing related
e $0 ressing site is dated. timed and initialed"
# Patient 'd%cation
a Patient ed%cation d%ring hospitali8ation is apparent
b Patient ed%cation is specific to care plan problems
& Transfer
a Transfer note completed by transferring %nit
b /dmission transfer note completed by admitting %nit"
Nursing Performance Assessment(8
( =egibility-=egality
a $s n%rsing record legibleD
b /re orders noted ith>
1 Time
2 ate
3 Signat%re of rsponsible 9
c )
1 'ach n%rsing notation
2 'nds each n%rsing page
e
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1!
1 ated2 Changed every &2 ho%rs reg%lar $06
3 Changed every 24 ho%rs hyperal6
c Site is clean and itho%t evidence of infiltration"
14 @ral ?ygeine of $ncapacitated Patients
a There is evidence of daily cleaning of teeth-dent%res
b $s patient on high dose and-or m%ltiple antibioticsD
c $f so. evidence of thr%shD
d octor notified of possible f%ngal infectionD
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e =ips and tong%e cleaned and most%rised
f ent%res are stored in containers labeled ith patients name and room n%mber
Nursing Performance Assessment (:
15 :oley Catheter Care
a :oleys catheter sec%red to patients thigh
b $s the catheter t%bing straight and free of kinks or coiling
c $s the straight drainage bag>
1 off the floor
2 Clean-free of odor
3 Placed at the right side of the bed patient is facing hen t%rned
4 ;elo the level of the patient bladder
d $s the catheter in good condition. free of tape or m%so%s b%ild%p
e $s %rine floing ell thro%gh the t%bingD onard directionD
f $s reason for the :oleys catheter doc%mentedD
1# Patient 'd%cation
a Can patient verbali8e %nderstanding of>
1 Pending proced%resD
2 eeded specimen collectionD
3 isease processD4 %rsing Care being deliveredD
5 ischarge-needs planningD
# oes patient verbali8e %nderstanding of pre)operative careD
& oes patient verbali8e %nderstanding of @T and recovery room careD
a6 /nesthesia
b6 :re7%ent vital signs
( oes patient verbali8e %nerstanding of post)operative careD
a6 T%rn. co%gh. deep breathD
b6 T%bes-e7%ipment to e+pectD
c6 P@ stat%s and diet advancementDd6 /vailability of pain medicationD
e6 $mportance of e+pressing feelingsD
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Performance Measures- /ritical /are 1nit
1 /ssessment of Patients
a /vailability of Physician
J F M A
1 e Cardiac patients seen ithin 4 ho%rs
2 /ll other ne admits seen ithin # ho%rs
3 Physician responds to 'mergency call ithin 3! min%tes
b 9et%rn to the Special Care nit ithin 4( ho%rs of transfer to a
loer level of care
11 Care of the Patient
a Standards of Care
1 Press%re ,onitoring
2 0entilator Patient Care
3 Temporary Pacer4 ,$-9@ ,$
5 C@P
# C?:
& Shock
( Pain ,anagement
* Thrombolytic Therapy
1! Skin $ntegrity
11 ?emodialysis
b $0 Therapy
c :oleys Catheter Care
d @ral ?ygeine of $ncapacitated patients
e ,edication se> medication errors
d , di ti C t
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d ,edication Carts
01 $nformation ,anagement
a oc%mentation
1 /ssessment
2 Plan of Care
3 ,edication
4 $ntake-@%tp%t
5 oc%mentation of $0 Care
# Patient 'd%cation
& Transfer( =egibility-=egality
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M J J A S O N D
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Operating oom-2nfection /ontrol /riteria
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Operating oom 2nfection /ontrol /riteria
1 $ndicator> $ntegrity of sterile field is maintained" ,et ot ,et
a S%rgical hand scr%b performed according to policy and proced%re"
b Proper goning and gloving techni7%e %sed"
c Sterile drapes placed on all tables %sed for e7%ipment and intr%ments"d Tables are clean and dry prior to %se
e $n draping. material held compact and above aist level and draping
done from operative site to periphery"
f /ll instr%ment trays shall be assembled. packaged. sterili8ed and stored according to standards
a Stored in proper area
b $tem is properly labelled"
c =ebel is legible
d Contains the folloing>
'+piration dates if applicable6
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Maintenance of Blood$Fluid Precautions in O7
$ndicator> Standard Preca%tions observed and maintaineda Aloves are orn hnever contact ith blood and body fl%ids is anticipated"
b Aloves are orn hen moving patients postoperatively
c Aloves are orn hen to%ching m%co%s membranes or open skin
d ?ands are ashed beteen patient contacts
e ?ands are ashed after accidental contact ith blood-body fl%ids and-or
after gloves are removed"
f ,asks and protective eye ear provided-orn henever aerosoli8ation
or splattering or blood-body fl%ids is anticipated e+t%bation. laryngoscopy etc6
g ,asks and protective eye ear provided-orn for all scr%bbed personnelh Sharp obects needles-blades6 are handled in s%ch a manner as to prevent
accidental c%ts-p%nct%res
i ;lood spills are cleaned immediately ith appropriate disinfectant"
/ll re%sable items are appropriately sterili8ed"
k sed needles are not broken-recapped. b%t are discarded in p%nct%re
resistant containers"
l se of appropriately labelled infectio%s aste-linen containers"
Patient 0;periences no 7issue Damage or /ompromised /irculation Pre)operative assessment and doc%mentation of patients physical stat%s is completed"
a Condition of skin notedb '+istence of abnormalities. in%ries. sensory impairment noted-doc%mented"
c Previo%s s%rgery"e+istence of metal implants noted-doc%mented
d Cast inspected for ade7%ate padding-protection
e /ppropriate-ade7%ate padding-positioning aids %sed
f Patient offered arm blanket. repositioned etc
g ?ypothermia %nit %sed according to man%fact%rers recommendations"
Psyc%ological Aspects of /are to Patients in t%e O7
$ndicator> E%ality and appropriateness of Psychological s%pport to patients in the @T
a /ssessment of Psychological aspectsb Patient enco%raged to ventilate concerns and fears
c E%estions ansered regarding n%rsing matters
d E%estions on ,edical Care referred to Physician
e 9oom preparations completed prior to patient entry
f oise-traffic minimi8e
g Patient orientated to operating room as needed
h Clear and concise e+planations given
i Patients emotional stat%s comm%nicated to other appropriate team members
Patient remained ith d%ring ind%ction
e $f t%rned. done on signal by anesthesiologist
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g y g
f ?ead t%rned gently and s%pported
Patient is free from 2n4ury elated to Positioning(contd
$ndicator> /ppropriateness of positioning of patients in @T
g 'ars and eyes protectedh Press%re prevented on chest incl%ding d%ring proced%re
i /rms placed on armboards. pronate palms. press%re on elbos prevented"
Safety strap in place
k Press%re points checked-padded
l o redness. br%ises. evidence of in%ry or press%re areass noted on -C form @T
m o problems ith circ%lation d%e to positioning noted
n Position-change in position doc%mented
Patient is free from in4ury elated to transfer from t%e O7 ta'le to t%e stretc%er
$ndicator> /de7%acy of lifting and moving patients in @T
a /de7%ate personnel are sec%red for help
b /ll body parts are s%pported d%ring move
c Patient moved ith %nison ith directions
d Proper body mechanics %sed by all personnel
e Consideration given to the patients condition
f Patient is made comfortable folloing move
g Safety strap-side rails etc. %tili8e
h There is no complaint from the patient regarding move
i There is no in%ry-complaint of the personnel
$0 and all other e7%ipment protected d%ring movek $0 and all e7%ipment remain intact folloing the move"
Maintenance of Fluid$0lectrolyte Balance
$ndicator> :l%id-'lectrolyte balance ill be maintained
a $ntake monitored and doc%mented
b @%tp%t monitored and doc%mented
c 'vidence of post)operative bleeding monitored-doc%mented
d Pre)operative res%lts checked
e /bnormal laboratory val%es comm%nicated to appropriate team members
f ;lood available as orderedg ;lood replacement initiated as ordered
h Post)operative na%sea-emesis noted-doc%mented
Patient is free from 2nury elated to 0lectrical #a6ards
$ndicator> The 'lectro)s%rgical nit 'S6 shall be %sed folloing all safety g%idelines in the @T
a 'S inspected by bio)medical ithin si+ months
b 'S clean and protected from spills
c 'S not %sed in presence of flammable agents
d Pl%g. cord and connections inspected before %se
e Cord reaches o%tlet itho%t stress
7 oc%mentation incl%des>Aenerator $ n%mber. Aro%nd pad placement-location.
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'KA pads placement-location. Patients skin condition before and after %se"
7rending S%eet
3ey Function$Performance Measures Benc%mar)
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y
1 Management of 2nformation
a" oc%mentation J F M A M J J A S O N D
1 Pre)op checklist complete and 9 signat%re 1!!F2 =aboratory-'KA res%lts on chart 1!!F
3 ? P on chart 1!!F
4 $f no ? P. evidence of ?-P dictated 1!!F
5 Consent for proced%re completed and signed 1!!F
# $f ?ysterectomy. special ?ysterectomy consent on chart" 1!!F
& Sterili8ation permit on chart if applicable 1!!F
( $nformed consent doc%mented on progress notes 1!!F
* $ndications for s%rgery doc%mented by physicians in 1!!F
charge in progess notes if patient is %nable to sign
and there is no g%ardian"
1! $ band on patient 1!!F
11 $nformed consent for blood if indicated 1!!F
12 $nformed consent for ;reast Cancer treatment if indicated6 1!!F
11 Sur!eillance= Pre!ention and /ontrol of 2nfections
1 $ntegrity of sterile field is maintained 1!!F
2 /ll instr%ment trays shall be assembled. packed.
sterili8ed and stored according to standard" 1!!F
3 Standard preca%tions observed-maintained in @T 1!!F
111 Assessment
1 Pre)operative assessment and doc%mentation of
patients physical stat%s is completed" 1!!F10 /are of Patient
1 E%ality and appropriateness of psychological s%pport
to patients in the operating room" 1!!F
2 /ppropriateness of positioning of patients in @T 1!!F
3 /de7%acy of lifting and moving patients in @T 1!!F
4 :l%id and electrolyte balance is maintained" 1!!F
0 Management of t%e 0n!ironment of /are
1 'S 'lectrical S%rgical nit6 shall be %sed folloing
all safety g%idelines in @T
01 Organisational Performance 2mpro!ement1 $ntraoperative readiness of @perating room staff 1!!F
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