somcquality dashboard - fy 12 patient-centered perfection is the goal safety quality service ...
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SOMCQuality Dashboard - FY 12 Patient-Centered Perfection is the Goal
Safety Quality Service Relationships Performance
Indicator Goal HC ? Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun YTD
Improve Quality of Care – AMI InpatientAspirin at Arrival for AMI $
100% HC ? 100 100 95 100 100 100 100 100 100 95 100 100 99
Aspirin at Discharge for AMI $
100% HC ? 100 100 100 100 96 100 100 100 100 100 100 100 99
Beta Blocker at Discharge for AMI $
100% HC ? 100 100 100 95 100 100 100 100 100 100 97 100 99
ACE Inhibitor/ARB at Discharge for AMI for LVSD less then 40 $
100% HC ? 100 100 100 100 100 100 100 100 100 100 100 100 100
Smoking Cessation Advice for AMI $
100% HC ? 100 100 100 100 100 100 100
Door to P.C.I. ≤ 90 Minutes for AMI $
100% HC ? 100 100 100 100 N/A 100 100 100 100 100 100 100 100
Statin at Discharge for AMI $
100% ? 100 96 100 95 100 100 100 100 100 100 97 100 99
Improve Quality of Care – CHF InpatientACE Inhibitor/ARB at Discharge for CHF for LVSD less than 40 $
100% HC ? 100 100 100 100 100 100 100 100 100 100 100 100 100
LV Function Assessment for CHF $
100% HC ? 100 100 96 100 100 100 100 100 100 100 100 100 99
Smoking Cessation Advice for CHF $
100% HC ? 100 100 100 100 100 100 100
Discharge Instructions for CHF $
100% HC ? 100 100 95 100 100 100 100 100 100 100 100 100 99
Improve Quality of Care – C.A.P. Inpatient
Blood Culture Before Antibiotic for C.A.P. $ 100% HC ? 100 100 100 100 100 98 100 100 98 100 100 100 99
Antibiotic Timing <6hrs for C.A.P. $
100% HC ? 100 100 100 100 98 100 99
Appropriate Initial Antibiotic Selection for C.A.P. $
100% HC ? 100 100 100 97 97 100 100 100 97 97 94 100 98
Pneumococcal Vaccine for Eligible Patients $ 100% HC ? 100 100 100 100 100 100 100
Influenza Vaccine for Eligible Patients (Oct 1st – Mar 31st ) $
100% HC ? N/A N/A N/A 100 100 100 100
Smoking Cessation Advice for C.A.P. $
100% HC ? 100 100 100 100 100 100 100
? = Explanation/Calculation HC = Hospital Compare
Task List Data Sheet
$
Safety Quality Service Relationships Performance
Indicator Goal HC ? Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun YTD
Immunization Measures
Pneumococcal Immunization – Overall Rate $
100% ? 100 100 97 100 98 98 99
Influenza Immunization – Overall Rate $
100% ? 93 92 93 N/A N/A N/A 93
Improve Quality of Care – Surgical Inpatient
Foley Catheter Removed on POD 1 or POD 2 $
100% HC ? 100 97 100 100 100 97 100 100 100 100 100 100 99
Normothermia on all Surgical Patients $
100% HC ? 100 100 100 100 100 100 100 100 100 100 100 100 100
Antibiotic Within 1 Hour Before Surgical Incision $
100% HC ? 100 98 98 100 98 98 94 100 100 100 100 98 99
Prophylactic Antibiotic Discontinued Within 24 Hours for Surgery Patients $
100% HC ? 100 100 96 100 100 98 100 98 98 100 100 100 99
Appropriate Prophylactic Antibiotic Selection for Surgery Patients $
100% HC ? 98 100 98 100 98 98 97 98 100 100 100 100 99
Surgery Patients With Appropriate Hair Removal $
100% HC ? 100 100 100 100 100 100 100 100 100 100 100 100 100
Major Cardiac Patients with Controlled (<200 mg/dl) 6am Post-op Serum Glucose on POD 1 and POD 2 $
100% HC ? 100 100 100 100 100 100 100 100 100 100 90 100 99
Surgery Patients on Beta Blockers Prior to Admission Who Receive Beta Blocker During Perioperative Period $
100% HC ? 100 100 100 100 100 100 95 96 100 100 100 100 99
V.T.E. Prophylaxis Ordered for Surgery Patients $ 100% HC ? 100 100 98 100 100 100 100 100 100 100 98 100 99
V.T.E. Prophylaxis Received Within 24 Hours Prior to or After Surgery $
100% HC ? 98 98 96 100 100 98 98 100 100 98 98 100 99
Improve Quality of Care – Emergency DepartmentMedian Time From ED Arrival to ED Departure for Admitted ED Patients ≤283 Minutes (SOMC Report) $
100% HC
?
100 100 100 100 96 100 100
Admit Decision Time to ED Departure Time for Admitted Patients ≤51 Minutes (SOMC Report) $
100% HC 100 100 93 100 59 82 94
? = Explanation/Calculation HC = Hospital Compare VBP = Value-Based Purchasing
$Task List Data Sheet
SOMCQuality Dashboard - FY 12 Patient-Centered Perfection is the Goal
Safety Quality Service Relationships Performance
Indicator Goal HC ? Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun YTD
Median Time From ED Arrival to ED Departure for Admitted ED Patients $
B.L HC
?
222 240 296 323 290 281 275
Admit Decision Time to ED Departure Time for Admitted Patients $
B.L HC 8479.5
113 103 91 71 90
Stroke Measures - Inpatient
Venous Thromboembolism (VTE) Prophylaxis 100% ? 75 100 86 92 100 92 100 100 100 88 100 100 94
Discharged on Antithrombotic Therapy 100% ? 100 100 100 100 100 100 100 100 93 100 100 100 99
Anticoagulation Therapy for Atrial Fibrillation/Flutter
100% ? N/A 100 100 100 100 67 50 100 N/A 50 100 100 80
Thrombolytic Therapy 100% ? 0 0 N/A N/A N/A N/A N/A N/A N/A N/A N/A 100 33Antithrombotic Therapy by end of Hospital Day 2
100% ? 100 91 100 100 100 100 100 100 100 89 100 100 99
Discharged on Statin Medication 100% ? 88 100 88 100 100 100 100 100 75 90 92 100 95
Stroke Education 100% ? 100 100 100 100 80 85 100 57 75 100 100 100 91
Assessed for Rehabilitation 100% ? 83 83 100 100 100 100 86 100 100 100 100 100 96
Improve Quality of Care – Surgical Outpatient
Appropriate Prophylactic Antibiotic Initiated Within One Hour Prior to Surgical Incision $
100% HC ? 100 100 100 100 100 100 100 100 100 100 100 100 100
Appropriate Prophylactic Antibiotic Selection for Surgical Patients $
100% HC ? 100 100 100 100 100 100 100 100 100 100 94 95 99
Improve Quality of Care – Chest Pain/AMI Outpatient
Aspirin at Arrival For Chest Pain/AMI $
100% HC ? 100 100 100 100 100 N/A 100 100 100 100 67 100 97
Percent of ECGs for Chest Pain/AMI Meeting the National Median Time of 4 Minutes or Less Prior to Transfer $
100% HC ? 100 75 100 100 100 N/A 67 75 60 0 100 67 77
Troponin Results for ED Acute Myocardial Infarction (AMI) Patients or Chest Pain Patients (With Probable Cardiac Chest Pain) Received Within 60 Minutes of Arrival $
B.L. ? 67 50 40 0 0 20 32
? = Explanation/Calculation HC = Hospital Compare
$Task List Data Sheet
SOMCQuality Dashboard - FY 12 Patient-Centered Perfection is the Goal
Safety Quality Service Relationships Performance
Indicator Goal HC ? Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun YTD
Median Time From ED Arrival to ED Departure for ED Patients – Overall Rate $
B.L. ? 170 131 166 137 198 148 158
Door to Diagnostic Evaluation by a Qualified Medical Personnel $
B.L. ? 13 9 21 48 42 34 27.8
Median Time to Pain Management for Long Bone Fracture $
B.L. ? 59.5 44 72 54 46 67 57
Left Without Being Seen $
B.L. ? 0.620.19
1.74 3.352.33
1.57 1.05
Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretations Within 45 Minutes of ED Arrival $
B.L. ? 0 N/A 100 N/A N/A 100 67
Structural MeasuresStructural Measures $
100% ? Yes 100
YTD Rate of Perfection 96.1%
? = Explanation/Calculation HC = Hospital Compare
$Task List Data Sheet
SOMCQuality Dashboard - FY 12 Patient-Centered Perfection is the Goal
S a f e t y Q u a l i t y S e r v i c e R e l a t i o n s h i p s P e r f o r m a n c e
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