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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