This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
SFGH Inpatient Dashboard: Key Operational and Quality Metrics
Improving Health
Outcomes
Optimizing Efficiency and
Access
Improving the Patient
Experience
For more detail on Harm results, see Patient Safety Dashboard (pg 3). For more detail on Core Measures, see Core Measures
dashboard (pg. 2)
67 69 77 74
81
Dec-13 Jan-14 Feb-14 Mar-14
Communication w/ Drs
SFGH NRC Avg
57 66 71 69
79
Dec-13 Jan-14 Feb-14 Mar-14
Communication w/ RNs
SFGH NRC Avg
53 58 64 65
71
Dec-13 Jan-14 Feb-14 Mar-14
Overall Rating of SFGH
SFGH NRC Avg
56
68 60
65
72
Dec-13 Jan-14 Feb-14 Mar-14
Pain Management
SFGH NRC Avg
0.90 0.82
1.18
0.76 0.84
Dec-13 Jan-14 Feb-14 Mar-14
Mortality O/E
SFGH NAPH Median
5.56
5.81 5.70
5.31
5.69
Dec-13 Jan-14 Feb-14 Mar-14
Avg LOS
SFGH NAPH Median
11% 13% 12%
9%
Dec-13 Jan-14 Feb-14
30 day Readmissions %
SFGH NAPH Median
474 435
474 495
338
2013-1 2013-2 2013-3 2013-4
ED arrival to Admit time (mins)
SFGH UHC Median
288 280 256 239
180
2013-1 2013-2 2013-3 2013-4
ED arrival to discharge time (mins)
SFGH UHC Median
93% 97%
80%
100%
AMI SCIP PN HF
Core measure composites Q4 2013
SFGH UHC Median
20
10
17
23
Oct-13 Nov-13 Dec-13 Jan-14
Instances of Harm
12.6% 10.6% 10.6% 9.1%
76% 70% 66%
50%
2013-2 2013-3 2013-4 2014-1
% Days at Lower Level of Care
MedSurg Psych
Brought to you by the Quality Data Center: Informing, engaging, and transforming practice through clinical and operational data.
SFGH Inpatient Dashboard: Key Operational and Quality Metrics
NOTES/DEFINITIONS
Operational and Quality metrics were selected based on SFGH strategic goals and external measurement by agencies like
CMS, Joint Commission, and America's Essential Hospitals (formerly NAPH). Metrics are organized around CMS's triple aim to
improve health outcomes, optimize efficiency and access, and improve patient experience.
UHC Median: Comparisons are based on the median score of all hospitals in the University Healthsystem Consortium (UHC);
they are not specific to service.
NAPH Median: National Association of Public Hospitals (now America's Essential Hospitals) median is used when available for
comparison to similar public hospitals.
Core Measure Composites: Each composite represents the total measure compliance for all eligible cases. Core Measures
are calculated by our Joint Commission vendor, the University Healthcare Consortium (UHC) and assesses inpatient clinical
performance with Acute Myocardial Infarction (AMI), Heart Failure (HF), Surgical Care (SCIP), and Pneumonia (PN). Core
measure results affect up to 2% of SFGH's Medicare fee-for service annual reimbursements, as part of the CMS Value Based
Purchasing program.
30 day Readmission Rate: The all-cause readmission rate is the proportion of patients who return to the hospital within 30
days of discharge from the prior (index) admission for all causes. Chemotherapy, radiation therapy, dialysis, rehabilitation
and delivery/birth are excluded from the numerator, and alcohol abuse and mental health cases are included in the
numerator and denominator. Bad data and deaths at first admission are excluded from the numerator and denominator.
The calculation formula is: Readmission Rate = number of readmissions/number of index admissions. This rate is taken from
UHC’s Readmissions report.
Mortality O/E: The mortality O/E ratio are taken from UHC’s Patient Outcomes Report, which looks at the same population
described in “Total Cases” above. The Mortality O/E is observed mortality rate divided by the UHC expected mortality rate.
A Mortality O/E of greater than 1 indicates that more patients died than expected. A Mortality O/E of less than 1 indicates
that fewer patients died than expected.
Instance of Harm: A monthly count of all instances of avoidable harm that happened at SFGH in one of the following