Clinical Performance and Employee Safety Metrics Executive ... · 8.00 9.00 10.00 2019-Q1 2019-Q2...

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CLINICAL AND SAFETY PERFORMANCE METRICS Executive Dashboard

NIH Clinical Center July 2020

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

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Overall Hospital Rating

50

55

60

65

70

75

80

85

90

95

100

Q1 CY 2019 Q2 CY 2019 Q3 CY 2019 Q4 CY 2019 Q1 CY 2020

Perc

ent P

ositi

ve R

espo

nse

Overall Rating of NIH CC - Inpatient Overall Rating of NIH CC - Outpatient

CMS HCAHPS Benchmark (Average) NRC Benchmark (Average)3

Would You Recommend the NIH CC?

50

55

60

65

70

75

80

85

90

95

100


Perc

ent P

ositi

ve R

espo

nse

Would Recommend NIH CC - Inpatient Would Recommend NIH CC - Outpatient

CMS HCAHPS Benchmark (Average) NRC Benchmark (Average)4

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

• Surgical Site Infections 5

Hand Hygiene Compliance

75%

80%

85%

90%

95%

100%

2019-Q1 2019-Q2 2019-Q3 2019-Q4 2020-Q1

Perc

ent A

dher

ence

6

Wholehouse Central-Line Associated Bloodstream Infection (CLABSI) Rate

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

2019-Q1 2019-Q2 2019-Q3 2019-Q4 2020-Q1

Infe

ctio

ns p

er 1

,000

cat

hete

r day

s

7

ICU Central-Line Associated Bloodstream Infection (CLABSI) Rate

0.00

0.20

0.40

0.60

0.80

1.00

1.20

2019-Q1 2019-Q2 2019-Q3 2019-Q4 2020-Q1

Infe

ctio

ns p

er 1

,000

cat

hete

r day

s

ICU CLABSI Rate NHSN ICU Benchmark

2013 CDC National Healthcare Safety Network (NHSN) Benchmark: Critical Care Units, Medical/Surgical -major teaching mean 1.1 8

ICU Catheter-Associated Urinary Tract Infections (CAUTI) Rate

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

2019-Q1 2019-Q2 2019-Q3 2019-Q4 2020-Q1

Infe

ctio

ns p

er 1

,000

fole

y da

ys

ICU CAUTI Rate NHSN ICU Benchmark

2013 CDC National Healthcare Safety Network (NHSN) Benchmark: Critical Care Units, Medical/Surgical -major teaching mean 2.7 9

Surgical Oncology Catheter-Associated Urinary Tract Infections (CAUTI) Rate

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

2019-Q1 2019-Q2 2019-Q3 2019-Q4 2020-Q1

Infe

ctio

ns p

er 1

,000

fole

y da

ys

Surgical Oncology CAUTI Rate NHSN Medical/Surgical Benchmark

2013 CDC National Healthcare Safety Network (NHSN) Benchmark: Inpatient Wards, Medical/Surgical mean 1.3 10

Q1 Data Pending

Surgical Site Infections (SSI) Rate

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

2019-Q1 2019-Q2 2019-Q3 2019-Q4 2020-Q1

Infe

ctio

ns p

er 1

00 p

roce

dure

s

SSI Rate 2018 Clinical Center Average

Q1 Data Pending

Q3 CY 2019 Data Pending 11

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

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Inpatient Falls Rate

0.00

0.50

1.00

1.50

2.00

2.50

3.00


Falls

per

1,0

00 p

atie

nt d

ays

Quarterly Rate NDNQI Benchmark Inpatient Falls with Injury

Q1 NDNQI Benchmark Pending

NDNQI benchmark for Total Falls Rate Only 13

Pressure Injury Prevalence

0

0.5

1

1.5

2

2.5

3

3.5


% o

f sur

veye

d pa

tient

s with

pre

ssur

e in

jury

Quarterly Rate National Mean (NDNQI) Stage 3 + 4 Pressure Injury PrevalenceNDNQI Benchmark for Total Pressure Injury Rate only 14

Medication Administration Barcode Use

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%


% B

arco

de U

se

Clinical Center Rate Goal

Beginning Q1 CY 2020 contrast media excluded from KBMA data

Emergency Response • Code Blue and Rapid Response

• Types of Patients • Types of Events • Patient Disposition

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Code Blue Response: Types of "Patients"

Q2 CY 2019 Q3 CY 2019 Q4 CY 2019 Q1 CY 2020 TotalInpt 23 21 15 23 82Outpt 21 14 19 20 74Employee 13 7 14 12 46Visitor 2 5 5 4 16Incorrect Calls 0 0 0 0 0

0

50

100

150

200

250N

umbe

r

17

Code Blue Response: Types of Events

Q2 CY 2019 Q3 CY 2019 Q4 CY 2019 Q1 CY 2020 TOTALBrain Code 6 0 3 9Arrest 0 1 1 5 7Acute Emergency 34 19 29 15 97Stable Event 25 21 23 36 105

0

50

100

150

200

250N

umbe

r

18

Code Blue Response: Patient Disposition

Q2 CY 2019 Q3 CY 2019 Q4 CY 2019 Q1 CY 2020 TOTALTransfer to ICU 17 17 9 12 55Transfer to OSH 16 12 21 13 62Remained on Unit 18 11 15 22 66Expired 0 1 0 0 1Released 1 2 2 3 8Other 7 4 6 9 26

0

50

100

150

200

250N

umbe

r

19

Rapid Response Team: Patient Disposition

Q2 CY 2019 Q3 CY 2019 Q4 CY 2019 Q1 CY 2020 TotalICU 7 9 4 8 28Unit/Other 1 2 2 2 7Remained on Unit 8 31 10 15 64

0

20

40

60

80

100

120N

umbe

r

20

Blood and Blood Product Use • Crossmatch to Transfusion (C:T) Ratio • Transfusion Reaction by Class • Unacceptable Blood Bank Specimens

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Crossmatch to Transfusion (C/T) Ratio (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.)

0.00

0.50

1.00

1.50

2.00

2.50


C/T Ratio CC C/T Ratio Goal

Cros

smat

ch to

Tra

nsfu

sed

Uni

ts R

atio

22

Transfusion Reactions by Class

0.00%

0.05%

0.10%

0.15%

0.20%

0.25%

0.30%

0.35%

0.40%

0.45%

0.50%


Perc

ent o

f Tra

nsfu

sions

Anaphylactic Other Febrile, Nonhemolytic Hemolytic, Septic, Anaphylactoid, and TRALI23

Unacceptable Blood Bank Specimens

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%


Perc

ent U

nacc

epta

ble

Spec

imen

s

% Specimens with Collection Problems CC Threshold24

Clinical Documentation • Medical Record Completeness

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

• Accuracy of Coding

25

Delinquent Records (>30 days post discharge)

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%


% R

ecor

ds D

elin

quen

t Afte

r 30

Days

% Records Delinquent Joint Commission Benchmark26

"Agent for" Orders Countersignature Compliance

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


% V

erba

l Ord

ers S

igne

d in

72

Hour

s

% of Compliance CC Goal27

"Do Not Use" Abbreviation Adherence

75%

80%

85%

90%

95%

100%


% A

ppro

pria

te U

se o

f Abb

revi

atio

ns

Compliance with Abbreviation Use CC Goal28

Accuracy of Record Coding

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% A

ccur

acy

of C

odin

g

Accuracy of Coding CC Goal29

Employee Safety • Occupational Injury and Illness

30

Occupational Injuries and Illnesses for CC Employees

0

5

10

15

20

25

30

35

40


Num

ber o

f Cas

es

TRC ORC DAFW DJTR DART

TRC: Total Recordable Cases; ORC: Other Recordable Cases; DAFW: Days Away From Work; DJTR: Days Job Transfer, Restriction; DART: Days Away, Restricted or Transferred (DAFW + DJTR)

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Percent of Occupational Injuries and Illnesses Jan - Mar 2020 n= 21

Musculoskeletal 43%

Wounds 24%

Ergonomic 10%

Other 24%

32

Ergonomic10%

Clinical Performance and Employee Safety Metrics Executive ... · 8.00 9.00 10.00 2019-Q1 2019-Q2...

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