CLINICAL PERFORMANCE AND EMPLOYEE SAFETY METRICSExecutive Dashboard

NIH Clinical Center

October 2017

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

50

55

60

65

70

75

80

85

90

95

100

Qtr 1 2016 Qtr 2 2016 Qtr 3 2016 Qtr 4 2016 Qtr 1 2017 Qtr 2 2017

Per

cen

t P

osi

tive

Sco

reOverall Hospital Rating

Overall Rating of Hospital - Inpatient Overall Rating of Hospital - Outpatient

NRC Benchmark (Inpatient) CMS HCAHPS Benchmark (Inpatient)

50

55

60

65

70

75

80

85

90

95

100

Qtr 1 2016 Qtr 2 2016 Qtr 3 2016 Qtr 4 2016 Qtr 1 2017 Qtr 2 2017

Per

cen

t P

osi

tive

Res

po

nse

Would You Recommend the NIH CC?

Would Recommend Hospital - Inpatient Would Recommend Hospital - Outpatient

NRC Benchmark (Inpatient) CMS HCAHPS Benchmark (Inpatient)

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

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2 2017-Q3

Per

cen

t A

dh

eren

ce

Hand Hygiene Adherence

Data collected by Unit-based

Data collected by Independent Auditors

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2

Infe

ctio

ns

per

10

00

cat

het

er d

ays

Whole-house Central-Line Associated Bloodstream Infection (CLABSI) Rate

n=7n=6

n=6

0.00

2.00

4.00

6.00

8.00

10.00

12.00

2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2

Infe

ctio

ns

per

10

00

cat

het

er d

ays

ICU Central-Line Associated Bloodstream Infection (CLABSI) Rate

ICU CLABSI Rate NHSN ICU Benchmark

n=1

n=1n=1

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2 2017-Q3

Infe

ctio

n p

er 1

00

0 f

ole

y d

ays

ICU Catheter-Associated Urinary Tract Infections

ICU CAUTI Rate NHSN ICU Benchmark

n=1

0.00

2.00

4.00

6.00

8.00

10.00

12.00

2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017Q1 2017-Q2

Infe

ctio

ns

per

10

00

cat

het

er d

ays

Surgical Oncology Catheter-Associated Urinary Tract Infections

Surgical Oncology NHSN Benchmark

0

0.5

1

1.5

2

2.5

3

3.5

2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2

Infe

ctio

ns

per

10

0 P

roce

du

res

Surgical Site Infections (SSI) Rate

SSI Rate Clinical Center Average

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

0

0.5

1

1.5

2

2.5

3

3.5

2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2

Falls

per

10

00

pat

ien

t d

ays

Inpatient Falls Rate

Falls Rate NDNQI Benchmark

0%

1%

2%

3%

4%

5%

6%

2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2 2017-Q3

% o

f Su

rvey

ed P

atie

nts

wit

h H

osp

ital

-Acq

uir

ed P

ress

ure

Inju

ries

Pressure Injury Prevalence

CC Mean National Mean (NDNQI)

The uptick in pressure injuries is largely due to injuries associated with long complex operative cases. An

interdisciplinary team (nursing, surgery, anesthesia, wound care) reviewed OR positioning practices, use of

compression stockings, oral breakdown related to endotracheal tubes, etc..

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Med

icat

ion

Bar

cod

ing

Use

(%

)Knowledge Based Medication Administration (KBMA)

Medication Barcoding Usage Report

% KMBA Used Goal

Emergency Response• Code Blue and Rapid Response

• Types of Patients• Type of Event• Patient Disposition

16-Qtr 4 17-Qtr 1 17-Qtr 2 17-Qtr 3 Total

Inpt 10 15 21 12 58

Outpt 12 9 11 13 45

Employee 14 16 8 9 47

Visitor 3 2 3 4 12

Incorrect Calls 0 0 0 0 0

0

20

40

60

80

100

120

140

160

180N

um

be

r

Code Blue Response: Types of "Patients"

16-Qtr 4 17-Qtr 1 17-Qtr 2 17-Qtr 3 TOTAL

Arrest 1 2 5 2 10

Acute Emergency 14 14 10 9 47

Stable Event 25 26 28 27 106

0

20

40

60

80

100

120

140

160

180N

um

be

r

Code Blue Response: Type of Event

16-Qtr 4 17-Qtr 1 17-Qtr 2 17-Qtr 3 TOTAL

Transfer to ICU 12 10 14 7 43

Transfer to OSH 13 15 8 10 46

Remained on Unit 4 6 14 13 37

Expired 1 1 1 0 3

Released 3 2 2 1 8

Other 7 8 4 7 26

0

20

40

60

80

100

120

140

160

180N

um

be

r

Code Blue Response: Patient Disposition

16-Qtr 4 17-Qtr 1 17-Qtr 2 17-Qtr 3 Total

ICU 5 7 11 8 31

Unit/Other 1 0 1 0 2

Remained on Unit 5 10 14 13 42

0

10

20

30

40

50

60

70

80N

um

be

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

0.5

1

1.5

2

2.5

2015_Q4 2016_Q1 2016_Q2 2016_Q3 FY2016_Q4 FY2017_Q1 FY2017_Q2 FY2017_Q3

Cro

ssm

atch

to

Tra

nsf

use

d U

nit

s R

atio

Crossmatch to Transfusion (C:T) Ratio

C:T Ratio CC C:T Ratio Goal

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.

0.000

0.001

0.002

0.003

0.004

0.005

0.006

0.007

0.008

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

FY2015 FY2016 FY2017

Per

cen

t o

f Tr

ansf

usi

on

sTransfusion Reactions by Class

Anaphlactic and Other Febrile, Non Hemolytic Hemolytic, Septic, Anaphlactoid, and TRALI

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sept-17

Per

cen

t u

nac

cep

tab

le s

pec

imen

s

Unacceptable Blood Bank Specimens

Percent specimens with collection problems CC Threshold

Clinical Documentation• Medical Record Completeness

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

• Accuracy of Coding

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17

% r

eco

rds

del

inq

uen

t af

ter

30

day

sDelinquent Records

(>30 days post discharge)

Joint Commission Benchmark Delinquent Records

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% v

erb

al o

rder

s si

gned

in 7

2 h

ou

rs

"Agent for" Orders Countersignature Compliance

% of Compliance CC Goal

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2014-Q1 2014-Q2 2014-Q3 2014-Q4 2015-Q1 2015-Q2 2015-Q3 2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2 2017-Q3

% a

pp

rop

riat

e u

se o

f ab

bre

viat

ion

s"Do Not Use" Abbreviation Adherence

Compliance with Abbreviation Use CC Goal

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

2014-Q1 2014-Q2 2014-Q3 2014-Q4 2015-Q1 2015-Q2 2015-Q3 2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2

% a

ccu

racy

of

cod

ing

Accuracy of Record Coding

Accuracy of Coding CC Goal

New staff on-board;

transitioning to ICD-10

Employee Safety • Occupational Injury and Illness

0

5

10

15

20

25

30

35

40

TRC ORC DAFW DJTR DART

NU

MB

ER O

F C

ASE

S

OSHA CLASSIFICATIONS

Comparison of Occupational Injuries and Illnesses for CC Employees: 1st and 2nd Quarter 2017

1QTR 2QTR

• Two-thirds of M/S cases (12/18) occurred in Pharmacy.

• Eight M/S cases occurred in the new Intravenous Admixture Unit (IVAU)

• Total Recordable Cases (TRC) spiked with an increased number of Other Recordable Cases (ORC)

• Musculoskeletal trauma (M/S) without patient contact remains the most common OI

• Injuries in IVAU include repetitive motion injuries as well as body mechanics issues

• Hospital Safety and Occupational Medicine are working with IVAU staff to address ergonomic issues

52%

30%

9%

9%

Types of Occupational Injuries Reported in 2nd Quarter 2017 n=34

M/S Trauma Wounds ERGO Other