CCHHSQualityDashboard-DRAFT

Transcription

1 CCHHSQualityDashboard-DRAFT9..8 Falswith Injury Pressure Injury(Stage I&IV) Aug-7 Nov-7 Feb-8 May-8 Aug-8 Aug-7 Nov-7 Feb-8 May-8 Aug HospitalAcquiredConditions 07Q 07Q4 08Q 08Q HospitalAcquiredInfections(SIR) CDiff CAUTI CLABSI MRSA Jul-7 Jul Mo.AVG:77 CCHHSSeriousSafetyEvents TotalEvents 0.6% 40.% 50.% 8.9% MedicationErrorType Administration Monitoring Other Prescription PatientSafety

2 CCHHSQualityDashboard-DRAFT9..8 Operations Provident-WilingnesstoRecommendHospital -WilingnesstoRecommendHospital ACHN-OveralClinicAssessment 85% Goal % Goal % Goal 87. TopBoxScore 4 TopBoxScore 4 MeanScore 4 Jul-7 Sep-7 Nov-7 Jan-8 Mar-8 May-8 Jul-7 Sep-7 Nov-7 Jan-8 Mar-8 May-8 Jul-7 Sep-7 Nov-7 Jan-8 Mar-8 May-8 EDPatientsLeavingwithoutBeingSeen #PatientsLWBS 6.% Mo.AVG:5.% 4.% 4. SurgeryFirstCaseonTimeStarts PlaceHolder Aug-7 Goal Aug-8

3 CCHHSQualityDashboard-DRAFT9..8 HealthOutcomes CoreMeasure-VenousThromboembolism (VTE)Prevention HEDIS-DiabetesManagement:HbAc<8% Goal: %Ac<8 HEDIS75thPCTL: % 4 4 Provident Jul-7 Aug-7 Sep-7 Oct-7 Nov-7 Dec-7 Jan-8 Feb-8 Mar-8 Apr-8 May-8 Aug-7 Oct-7 Dec-7 Feb-8 Apr-8 Jun-8 Aug-8 DepressionScreeningReferralManagement 0 00 SocialWorkerSeen MedicationRx #PHQ9>=5 ReadmissionRate Placeholder Risk-AdjustedMortalityRate Placeholder Aug-7 Aug-8

4 Quality Dashboard Metrics Measure Type Measure Name Reasoning Measure Definition Source ACHN HEDIS-Diabetes Ac Strategic Plan Adults ages 8-75 with diabetes (type or type ) where HbAc is in control <8.. Will change to be <7.. CDC, NCQA, HEDIS The percentage of members years of age and older who were screened for NCQA, HEDIS Behavioral Health PHQ 9 Depression clinical depression using a standardized Strategic Plan/Behavioral Health ACHN Screening tool and, if screened positive, who received follow-up care either with a social worker visit or medication prescription Emergency Dept-- Inpatient Patients Left without Being Seen Core Measures-Influenza Vaccination (seasonal) Patient Throughput for ED Requirement Inpatient Core Measures-VTE &, Inpatient-- HAI- CAUTI / Inpatient-- HAI-C-DIFF / Inpatient-- HAI-CLABSI / Percentage of patients who left the emergency department before being seen Timely & effective care- Preventive care: Patients assessed and given influenza vaccination Percentage of surgical patients aged 8 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low- Dose Unfractionated Heparin (LDUH), adjusteddose warfarin, fondaparinux or mechanical prophylaxis to be given within 4 hours prior to incision time or within 4 hours after surgery end time Catheter-associated urinary tract infections (CAUTI) greater than 48 hours after admission Clostridium difficile (C.diff.) intestinal infections greater than 48 hours after admission Central line-associated bloodstream infections (CLABSI) greater than 48 hours after admission

5 Measure Type Measure Name Reasoning Measure Definition Source Inpatient-- HAI-MRSA / Methicillin-resistant Staphylococcus Aureus (MRSA) blood infections greater than 48 hours after admission Inpatient-- HAPI / Stage III or IV pressure ulcers or, AHRQ unstageable Inpatient Risk- Adjusted Mortality Adjustment for case mix differences and Rate service mix differences The readmission measures are estimates Inpatient Readmissions of unplanned readmission to an acute care hospital in the 0 days after discharge from a hospitalization. Patients may have had an unplanned readmission for any reason. A patient fall is an unplanned descent to, NDNQI the floor (or extension of the floor, e.g., Safety- Falls with Injury,AHRQ, trash can or other equipment) with or Patient Satisfaction- /Provident Patient Satisfaction- ACHN Surgical Services-- Safety- Serious safety events Safety-Med Errors IP-Willingness to Recommend Hospital OP-Overall Assessment % of First Cases Start on Time / /Funding /Operations without injury to the patient A Safety Event is a situation where best or expected practice does not occur. If this is followed by serious harm to a patient, then we call it a Serious Safety Event (SSE) With harm score 6,7,8 &9. Medical events that are related to medication and/or medication related issues The likelihood that a patient will recommend a hospital to family members and friends. Overall score for the service a patient received or has experienced Performance improvement project to increase the % of first surgical cases starting on time Press Ganey Press Ganey