HAAD quality KPI; waiting time

Transcription

1 Type: Waiting Time Indicator Indicator Number: WT001 Primary Care Appointment- Outpatient Setting Time to see a HAAD licensed family physician or member of their team (GP) Time of request (walk-in or by phone) to seeing the doctor Number of patients that were seen within 48 hours of requests DIVIDED by the number of all requests that attended Exclusions : 1) Non Physician Led Appointment Types 2) Follow Up Appointment Types 3) Dentist 4) Emergency Patients 5) Patient choice of not having the appointment within 48 hours when offered % for performance (hours for mean, median and min. & max) 90% within 48 hours -Local business intelligence report or any other internally designed system - Applicable to licensed operational general and specialist hospitals for provision of primary care and/or specialist/consultant outpatient facilities Page 1 of 18

2 Type: Waiting Time Indicator Indicator Number: WT002 Referral of Suspected Cancer Cases Time for a HAAD licensed relevant specialist/ consultant to see a patient with suspected cancer from time of receiving the referral Time from receiving the referral (or self-request for appointment) to seeing a relevant specialist/consultant Number of patients with suspected cancer that got seen by the relevant HAAD licensed specialist/consultant within 2 weeks (or 14 calendar days) from receiving the referral (or self-requested appointment) DIVIDED by the number of all attended referred (selfreferred) patients with suspected cancer Populations: All suspected cancer cases Exclusions : 1) Non Physician Led Appointment Types 2) Follow Up Appointment Types % for performance (days for mean, median and min. & max) 90% within 14 calendar days - Local business intelligence report or any other internally designed system - Applicable to licensed operational general and specialist hospitals for provision of primary care and/or specialist/consultant outpatient facilities - Referral forms or data base Page 2 of 18

3 Type: Waiting Time Indicator Indicator Number: WT003 Hospital Wait at Point of Arrival Time in minutes from registration to seeing a specialist or consultant Minutes difference from registration in attendance to seeing the specialist or consultant Number of patients that were seen within 60 minutes DIVIDED by the number of all patients registering Exclusions : - Non Physician Led Appointment Types - Patients that required investigation done prior to seeing the doctor, as part of efficient process e.g.; hearing test, treadmill test, ECG, blood glucose, etc.. % for performance (minutes for mean, median and min. & max) 90% within 60 minutes - Local business intelligence report or any other internally designed system - Applicable to licensed operational general and specialist hospitals for provision of primary care and/or specialist/consultant outpatient facilities Page 3 of 18

4 Type: Waiting Time Indicator Indicator Number: WT004 Consultant or specialist Hospital Appointment (excluding cancer) Time for a HAAD-licensed specialist or consultant to see a nonsuspected cancer case Time from receiving the referral (or self-request for appointment) to seeing a relevant specialist/consultant Number of patients that got seen by the relevant HAAD licensed specialist/consultant within 2 weeks (or 14 calendar days) from receiving the referral (or self-requested appointment) DIVIDED by the number of all referred (by all referred and/or self-requests) that attended Exclusions: 1) For / To Oncology Clinics 2) Non Physician Led Appointment Types 3) Follow Up Appointment Types % for performance (days for mean, median and min. & max) 90% within 14 calendar days - Local business intelligence report or any other internally designed system - Applicable to licensed operational general and specialist hospitals for provision of primary care and/or specialist/consultant outpatient facilities Page 4 of 18

5 Type: Waiting Time Indicator Indicator Number: WT005 Hospital Inpatient or day case (inpatient) Number of days it takes to admit a non- emergency patient from DTA (decision to admit) made by a HAAD licensed specialist or consultant Number of days from date of DTA (Decision to Admit) to nonemergency patient being admitted (DTA is day zero) for procedure and non-procedure based activities Number of patients being admitted within 28 days of DTA DIVIDED by all patients with DTA within the same set period Population: All elective admissions with DTA Exclusion: 1. Patients who are unable to have their treatment for social, work or personal reasons 2. Patients who choose to wait longer than 4-weeks for their treatment 3. Patients for whom it is not clinically appropriate to start treatment within 4 weeks 4. Delay in admission due to insurance approval being refused or delayed >= 14 days 5. Emergency admissions % for performance (days for mean, median and min. & max) 90% within 28 calendar days - Local business intelligence report or any other internally designed system - Applicable to facilities licensed to provide inpatient services Page 5 of 18

6 Type: Waiting Time Indicator Indicator Number: WT006 Door to Balloon (PCI) time for patients with ACAS Number of minutes it takes to start angiogram/plasty for emergency patients with ACAS diagnosis Acute myocardial infarction (AMI) patients with ST-segment elevation or LBBB on the ECG closest to arrival time receiving primary PCI during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less Number of patients having angiogram or angioplasty within 90 minutes DIVIDED by the number of all patients attending or registering with ACAS, AMI patients with ST-elevation or LBBB on ECG who received primary PCI Numerator: Number of patient who had primary angiogram/plasty within 90 min of attending as an emergency With ACAS Numerator Inclusions: n/a Numerator Exclusions: None Denominator: Number of all patients attending or registering with ACAS AMI patients with ST-elevation or LBBB on ECG who are indicated to receive primary PCI Denominator Inclusions: Discharged patients with: o An ICD-10-CM Principal Diagnosis Code for AMI: I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary I21.09 ST elevation (STEMI) myocardial infarction involving other coronary of anterior wall I21.11 ST elevation (STEMI) myocardial infarction involving right coronary Page 6 of 18

7 o o o I21.19 ST elevation (STEMI) myocardial infarction involving other coronary of inferior wall I21.29 ST elevation (STEMI) myocardial infarction involving other sites I21.4 Non-ST elevation (NSTEMI) myocardial infarction I21.3 ST elevation (STEMI) myocardial infarction of unspecified site AND CPT Principal and Other Procedure Codes for Percutaneous Coronary Intervention (PCI): Percutaneous transluminal coronary balloon angioplasty; single vessel Percutaneous transluminal coronary balloon angioplasty; each additional vessel (List separately in addition to code for primary procedure) Percutaneous transluminal coronary atherectomy, by mechanical or other method, with or without balloon angioplasty; single vessel Percutaneous transluminal coronary atherectomy, by mechanical or other method, with or without balloon angioplasty; each additional vessel (List separately in addition to code for primary procedure) AND/ OR ST-segment elevation or LBBB on the ECG performed closest to hospital arrival AND PCI performed within 24 hours after hospital arrival Denominator Exclusions: Patients less than 16 years of age In-Patients Patients enrolled in clinical trials Patients administered fibrinolytic agent or any counter indication agent prior to PCI in another facility if indicated PCI described as non-primary by a physician/advanced practice nurse/physician assistant (physician/apn/pa) PCI is clinically contraindicated % for performance (minutes for mean, median and min. & max) 90% within 90 minutes Page 7 of 18

8 - Local business intelligence report or any other internally designed system - Applicable to facilities licensed to provide inpatient services Page 8 of 18

9 Type: Waiting Time Indicator Indicator Number: WT007 KPI Description (title): Stroke Admission with CT scan timeframe Number of minutes it takes to start head CT-emergency scan for patients presenting with suspected stroke Number of minutes from registration or attending to start of emergency CTscan of head Number of patients having an emergency head CT-Scan for acute Stroke within 3 hours DIVIDED by all patients attending or registering with suspected stroke Numerator: Patients with suspected acute stroke who had a CT-Scan of the head within 180 minutes of arrival to ED. Denominator: All adult Patients (>=16 years old) who are suspected of having an acute stroke who have visited ED departments. Patients who arrive to ED with ACUTE symptoms suggestive of stroke, or defined as ischemic and hemorrhagic stroke patients. Suspected Acute Discharge, ICD 10 CM: Ischemic Stroke: I63.00 I I I I I63.02 I I I Cerebral infarction due to thrombosis of unspecified pre Cerebral infarction due to thrombosis of right vertebral Cerebral infarction due to thrombosis of left vertebral Cerebral infarction due to thrombosis of bilateral vertebral arteries Cerebral infarction due to thrombosis of unspecified vertebral Cerebral infarction due to thrombosis of basilar Cerebral infarction due to thrombosis of right carotid Cerebral infarction due to thrombosis of left carotid Cerebral infarction due to thrombosis of bilateral carotid arteries Page 9 of 18

10 I Cerebral infarction due to thrombosis of unspecified carotid I63.09 Cerebral infarction due to thrombosis of other pre I63.10 Cerebral infarction due to embolism of unspecified pre I Cerebral infarction due to embolism of right vertebral I Cerebral infarction due to embolism of left vertebral I Cerebral infarction due to embolism of bilateral vertebral arteries I Cerebral infarction due to embolism of unspecified vertebral I63.12 Cerebral infarction due to embolism of basilar I Cerebral infarction due to embolism of right carotid I Cerebral infarction due to embolism of left carotid I Cerebral infarction due to embolism of bilateral carotid arteries I Cerebral infarction due to embolism of unspecified carotid I63.19 Cerebral infarction due to embolism of other pre I63.20 stenosis of unspecified precerebral arteries I stenosis of right vertebral arteries I stenosis of left vertebral arteries I stenosis of bilateral vertebral arteries I stenosis of unspecified vertebral arteries I63.22 stenosis of basilar arteries I stenosis of right carotid arteries I stenosis of left carotid arteries I stenosis of bilateral carotid arteries I stenosis of unspecified carotid arteries I63.29 stenosis of other precerebral arteries I63.30 Cerebral infarction due to thrombosis of unspecified Page 10 of 18

11 I I I I I I I I I I I I I I I I I63.39 I63.40 I I I I I I I Cerebral infarction due to thrombosis of right middle Cerebral infarction due to thrombosis of left middle Cerebral infarction due to thrombosis of bilateral middle cerebral arteries Cerebral infarction due to thrombosis of unspecified middle Cerebral infarction due to thrombosis of right anterior Cerebral infarction due to thrombosis of left anterior Cerebral infarction due to thrombosis of bilateral anterior arteries Cerebral infarction due to thrombosis of unspecified anterior Cerebral infarction due to thrombosis of right posterior Cerebral infarction due to thrombosis of left posterior Cerebral infarction due to thrombosis of bilateral posterior arteries Cerebral infarction due to thrombosis of unspecified posterior Cerebral infarction due to thrombosis of right cerebellar Cerebral infarction due to thrombosis of left cerebellar Cerebral infarction due to thrombosis of bilateral cerebellar arteries Cerebral infarction due to thrombosis of unspecified cerebellar Cerebral infarction due to thrombosis of other Cerebral infarction due to embolism of unspecified Cerebral infarction due to embolism of right middle Cerebral infarction due to embolism of left middle Cerebral infarction due to embolism of bilateral middle cerebral arteries Cerebral infarction due to embolism of unspecified middle Cerebral infarction due to embolism of right anterior Cerebral infarction due to embolism of left anterior Cerebral infarction due to embolism of bilateral anterior cerebral arteries Page 11 of 18

12 I I I I I I I I I I63.49 I63.50 I I I I I I I I I I I I I I Cerebral infarction due to embolism of unspecified anterior Cerebral infarction due to embolism of right posterior Cerebral infarction due to embolism of left posterior Cerebral infarction due to embolism of bilateral posterior cerebral arteries Cerebral infarction due to embolism of unspecified posterior Cerebral infarction due to embolism of right cerebellar Cerebral infarction due to embolism of left cerebellar Cerebral infarction due to embolism of bilateral cerebellar arteries Cerebral infarction due to embolism of unspecified cerebellar Cerebral infarction due to embolism of other cerebral stenosis of unspecified stenosis of right middle stenosis of left middle stenosis of bilateral middle arteries stenosis of unspecified middle stenosis of right anterior stenosis of left anterior stenosis of bilateral anterior arteries stenosis of unspecified anterior stenosis of right posterior stenosis of left posterior stenosis of bilateral posterior arteries stenosis of unspecified posterior stenosis of right cerebellar stenosis of left cerebellar Page 12 of 18

13 I stenosis of bilateral cerebellar arteries I stenosis of unspecified cerebellar I63.59 stenosis of other I63.6 Cerebral infarction due to cerebral venous thrombosis, nonpyogenic I63.8 Other cerebral infarction I63.9 Cerebral infarction, unspecified Hemorrhagic Stroke: I60.00 Nontraumatic subarachnoid hemorrhage from unspecified carotid siphon and bifurcation I60.01 Nontraumatic subarachnoid hemorrhage from right carotid siphon and bifurcation I60.02 Nontraumatic subarachnoid hemorrhage from left carotid siphon and bifurcation I60.10 Nontraumatic subarachnoid hemorrhage from unspecified middle I60.11 Nontraumatic subarachnoid hemorrhage from right middle I60.12 Nontraumatic subarachnoid hemorrhage from left middle cerebral I60.2 Nontraumatic subarachnoid hemorrhage from anterior communicating I60.30 Nontraumatic subarachnoid hemorrhage from unspecified posterior communicating I60.31 Nontraumatic subarachnoid hemorrhage from right posterior communicating I60.32 Nontraumatic subarachnoid hemorrhage from left posterior communicating I60.4 Nontraumatic subarachnoid hemorrhage from basilar I60.50 Nontraumatic subarachnoid hemorrhage from unspecified vertebral I60.51 Nontraumatic subarachnoid hemorrhage from right vertebral I60.52 Nontraumatic subarachnoid hemorrhage from left vertebral I60.6 Nontraumatic subarachnoid hemorrhage from other intracranial arteries I60.7 Nontraumatic subarachnoid hemorrhage from unspecified intracranial I60.8 Other nontraumatic subarachnoid hemorrhage I60.9 Nontraumatic subarachnoid hemorrhage, unspecified I61.0 Nontraumatic intracerebral hemorrhage in hemisphere, subcortical I61.1 Nontraumatic intracerebral hemorrhage in hemisphere, cortical Page 13 of 18

14 I61.2 Nontraumatic intracerebral hemorrhage in hemisphere, unspecified I61.3 Nontraumatic intracerebral hemorrhage in brain stem I61.4 Nontraumatic intracerebral hemorrhage in cerebellum I61.5 Nontraumatic intracerebral hemorrhage, intraventricular I61.6 Nontraumatic intracerebral hemorrhage, multiple localized I61.8 Other nontraumatic intracerebral hemorrhage I61.9 Nontraumatic intracerebral hemorrhage, unspecified Exclusion: a. Patients below 16 years of age. b. Clinically unstable patients. Reported Information: % for performance (minutes for mean, median and min. & max) waiting time, median waiting time, min. & max. waiting time) 90% within 180 minutes - Local business intelligence report or any other internally designed system - Applicable to facilities licensed to provide inpatient services Page 14 of 18

15 Type: Waiting Time Indicator Indicator Number: WT008 Seeing a doctor in Accident and Emergency Number of minutes it takes from point of registration to seeing a doctor Number of patients seen within 60 minutes DIVIDED by all patients registering in A&E Population: All emergency encounters Exclusion: 1) Deceased on Arrival (DOA) 2) Patient Left Without Being Seen (LWBS) % for performance (minutes for mean, median and min. & max) 90% within 60 minutes - Local business intelligence report or any other internally designed system - Applicable to facilities licensed to provide emergency and inpatient services Page 15 of 18

16 Type: Waiting Time Indicator Indicator Number: WT009 Registration to leaving Accident and Emergency Department Number of minutes from registration to patient leaving the department (admitted, discharged, deceased) Number of patients that left the A & E department within 120 minutes DIVIDED by all patients attending A & E Population: All emergency encounters ( irrespective of triage category) Exclusion: 1) Deceased on Arrival (DOA) % for performance (minutes for mean, median and min. & max) 90% within 120 minutes - Local business intelligence report or any other internally designed system - Applicable facilities licensed to provide emergency and inpatient services Page 16 of 18

17 Type: Waiting Time Indicator Indicator Number: WT010 Emergency Ambulance response time in Urban Areas Time, in minutes, it requires an ambulance to arrive to emergency scene in an urban areas from time of request Number of ambulance responses that arrived at scene within 15 minutes of request DIVIDED by all requests from urban areas Population: All actioned ambulance calls Exclusion: 1) non-dispatched calls 2) inter-facilities transfer e.g., clinic to hospital or hospital to hospital % for performance (minutes for mean, median and min. & max) 90% within 15 minutes - Ambulance provider intelligence report or any other internally designed system - Applicable to licensed ambulance services Page 17 of 18

18 Type: Waiting Time Indicator Indicator Number: WT011 Emergency Ambulance response time in Rural Areas Time, in minutes, it requires an ambulance to arrive to emergency scene in a rural areas from time of request Number of ambulance responses that arrived at scene within 19 minutes of request DIVIDED by all requests from urban areas Population: All actioned ambulance calls Exclusion: 3) non-dispatched calls 4) inter-facilities transfer e.g., clinic to hospital or hospital to hospital % for performance (minutes for mean, median and min. & max) 90% within 19 minutes - Ambulance provider intelligence report or any other internally designed system - Applicable to licensed ambulance services Page 18 of 18