clinical and safety performance metrics (april 2021)

CLINICAL AND SAFETY PERFORMANCE METRICSExecutive Dashboard

NIH Clinical CenterApril 2021

Patients’ Perceptions• Overall Hospital Rating• Would you Recommend the NIH CC?

50

55

60

65

70

75

80

85

90

95

100

Q4 CY 2019 Q1 CY 2020 Q2 CY 2020 Q3 CY 2020 Q4 CY 2020

Perc

ent P

ositi

ve R

espo

nse

Overall Hospital Rating

Overall Rating of NIH CC - Inpatient Overall Rating of NIH CC - Outpatient

CMS HCAHPS Benchmark (Average) NRC Benchmark (Average)

50

55

60

65

70

75

80

85

90

95

100


Perc

ent P

ositi

ve R

espo

nse

Would You Recommend the NIH CC?

Would Recommend NIH CC - Inpatient Would Recommend NIH CC - Outpatient

CMS HCAHPS Benchmark (Average) NRC Benchmark (Average)

Infection Control Metrics • Hand Hygiene• Central-Line Associated Bloodstream Infections

• Whole-house• Intensive Care Unit

• Catheter Associated Urinary Tract Infections• Intensive Care Unit• Surgical Oncology

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

2019-Q4 2020-Q1 2020-Q2 2020-Q3 2020-Q4

Perc

ent A

dher

ence

Hand Hygiene Compliance

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

2019-Q4 2020-Q1 2020-Q2 2020-Q3 2020-Q4

Infe

ctio

ns p

er 1

,000

cat

hete

r day

sWholehouse Central-Line Associated Bloodstream Infection (CLABSI) Rate

0.00

0.50

1.00

1.50

2.00

2.50

3.00

2019-Q4 2020-Q1 2020-Q2 2020-Q3 2020-Q4

Infe

ctio

nspe

r 1,0

00 c

athe

ter d

ays

ICU Central-Line Associated Bloodstream Infection (CLABSI) Rate

ICU CLABSI Rate NHSN ICU Benchmark2013 CDC National Healthcare Safety Network (NHSN) Benchmark: Critical Care Units, Medical/Surgical -major teaching mean 1.1

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

2019-Q4 2020-Q1 2020-Q2 2020-Q3 2020-Q4

Infe

ctio

ns p

er 1

,000

fole

y da

ys

ICU Catheter-Associated Urinary Tract Infections (CAUTI) Rate

ICU CAUTI Rate NHSN ICU Benchmark2013 CDC National Healthcare Safety Network (NHSN) Benchmark: Critical Care Units, Medical/Surgical -major teaching mean 2.7

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

2019-Q4 2020-Q1 2020-Q2 2020-Q3 2020-Q4

Infe

ctio

ns p

er 1

,000

fole

y da

ysSurgical Oncology Catheter-Associated Urinary Tract Infections

(CAUTI) Rate

Surgical Oncology CAUTI Rate NHSN Medical/Surgical Benchmark2013 CDC National Healthcare Safety Network (NHSN) Benchmark: Inpatient Wards, Medical/Surgical mean 1.3

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

2019-Q4 2020-Q1 2020-Q2 2020-Q3 2020-Q4

Infe

ctio

ns p

er 1

00 p

roce

dure

s

Surgical Site Infections (SSI) Rate

SSI Rate 2018 Clinical Center Average

Nursing Quality Metrics • Falls• Pressure Injury• Medication Administration Barcoding

0.00

0.50

1.00

1.50

2.00

2.50

3.00

Q3 CY 2019 Q4 CY 2019 Q1 CY 2020 Q2 CY 2020 Q3 CY 2020 Q4 CY 2020

Falls

per

1,0

00 p

atie

nt d

ays

Inpatient Falls Rate

Quarterly Rate NDNQI Benchmark Inpatient Falls with Injury

0

1

2

3

4

5

6

7


% o

f sur

veye

d pa

tient

s w

ith p

ress

ure

inju

ry

Pressure Injury Prevalence

Quarterly RateNDNQI Benchmark for Total Pressure Injury Rate only

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%


% B

arco

de U

se

Medication Administration Barcode Use

Clinical Center Rate Goal

Emergency Response• Code Blue and Rapid Response

• Types of Patients• Type of Event• Patient Disposition

Q1 CY 2020 Q2 CY 2020 Q3 CY 2020 Q4 CY 2020 TotalInpt 23 6 20 23 72Outpt 20 1 6 12 39Employee 12 4 10 10 36Visitor 4 2 1 2 9Incorrect Calls 0 0 0 0 0

0

20

40

60

80

100

120

140

160

180N

umbe

r

Code Blue Response: Types of "Patients"

Q1 CY 2020 Q2 CY 2020 Q3 CY 2020 Q4 CY 2020 TOTALBrain Code 3 0 0 2 5Arrest 5 0 6 3 14Acute Emergency 15 9 21 24 69Stable Event 36 4 9 18 67

0

20

40

60

80

100

120

140

160

180N

umbe

r

Code Blue Response: Type of Event

Q1 CY 2020 Q2 CY 2020 Q3 CY 2020 Q4 CY 2020 TOTALTransfer to ICU 12 4 15 13 44Transfer to OSH 13 4 9 14 40Remained on Unit 22 4 10 11 47Expired 0 0 1 1 2Released 3 1 0 0 4Other 9 0 1 8 18

0

20

40

60

80

100

120

140

160

180N

umbe

r

Code Blue Response: Patient Disposition

Q1 CY 2020 Q2 CY 2020 Q3 CY 2020 Q4 CY 2020 TotalICU 8 2 5 4 19Unit/Other 2 0 6 1 9Remained on Unit 15 3 5 17 40

0

10

20

30

40

50

60

70

80N

umbe

r

Rapid Response Team: Patient Disposition

Blood and Blood Product Use• Crossmatch to Transfusion (C:T) Ratio• Transfusion Reaction by Class• Unacceptable Blood Bank Specimens

0.00

0.50

1.00

1.50

2.00

2.50


Cros

smat

ch to

Tra

nsfu

sed

Uni

ts R

atio

Crossmatch to Transfusion (C/T) Ratio(The NIH CC goal is to have a C:T ratio of 2.0 or less. Monitoring this metric ensures that blood is not held unused in reserve when it

could be available for another patient.)

C/T Ratio CC C/T Ratio Goal

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

1.40%


Perc

ent o

f Tra

nsfu

sion

s

Transfusion Reactions by Class

Anaphylactic Other Febrile, Nonhemolytic Hemolytic, Septic, Anaphylactoid, and TRALI

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%


Perc

ent U

nacc

epta

ble

Spec

imen

sUnacceptable Blood Bank Specimens

% Specimens with Collection Problems CC Threshold

Clinical Documentation• Medical Record Completeness

• Delinquent Records• “Agent for” Countersignature Adherence• Unacceptable Abbreviation Use

• Accuracy of Coding

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%


% re

cord

s de

linqu

ent a

fter

30

days

Delinquent Records(>30 days post discharge)

% Records Delinquent Joint Commission Benchmark

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


% v

erba

l ord

ers s

igne

d in

72

hour

s

"Agent for" Orders Countersignature Compliance

% of Compliance CC Goal

75%

80%

85%

90%

95%

100%


% a

ppro

pria

te u

se o

f abb

revi

atio

ns"Do Not Use" Abbreviation Adherence

Compliance with Abbreviation Use CC Goal

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% a

ccur

acy

of c

odin

g

Accuracy of Record Coding

Accuracy of Coding CC Goal

Employee Safety • Occupational Injury and Illness

0

1

2

3

4

5

6

7

8

2017 2018 2019 2020

Case

Inci

denc

e Ra

teOccupational Injuries and Illnesses for CC Employees

TRC ORC DAFW DJTR DARTTRC: Total Recordable Cases; ORC: Other Recordable Cases; DAFW: Days Away From Work; DJTR: Days Job Transfer, Restriction; DART: Days Away, Restricted or Transferred (DAFW + DJTR)

clinical and safety performance metrics (april 2021)

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