Clinical Performance and Employee Safety Metrics · · 2017-12-27CLINICAL PERFORMANCE AND...
Transcript of Clinical Performance and Employee Safety Metrics · · 2017-12-27CLINICAL PERFORMANCE AND...
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CLINICAL PERFORMANCE AND EMPLOYEE SAFETY METRICSExecutive Dashboard
NIH Clinical Center
April 2018
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Patients’ Perceptions• Overall Hospital Rating• Would you Recommend the NIH CC?
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Overall Hospital Rating
Overall Rating of NIH CC - Inpatient Overall Rating of NIH CC - Outpatient
CMS HCAHPS Benchmark (Average) NRC Benchmark (Average)
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Would You Recommend the NIH CC?
Would Recommend NIH CC - Inpatient Would Recommend NIH CC - Outpatient
CMS HCAHPS Benchmark (Average) NRC Benchmark (Average)
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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
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Hand Hygiene Adherence 2017
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Wholehouse Central-Line Associated Bloodstream Infection (CLABSI) Rate
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ICU Central-Line Associated Bloodstream Infection (CLABSI) Rate
ICU CLABSI Rate NHSN ICU Benchmark
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ICU Catheter-Associated Urinary Tract Infections (CAUTI)Rate
ICU CAUTI Rate NHSN ICU Benchmark
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Surgical Oncology:Catheter-Associated Urinary Tract Infections
Surgical Oncology NHSN Benchmark
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Surgical Site Infections (SSI) Rate
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Nursing Quality Metrics • Falls• Pressure Injury• Medication Administration Barcoding
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Falls Rate NDNQI Benchmark
1st Quarter NDNQI Benchmark pending
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inju
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CC Mean National Mean (NDNQI)
1st Quarter NDNQI Benchmark pending
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100%
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% B
arco
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Use
Medication Administration Barcode Use
EHRDowntime
EHRDowntime
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Emergency Response• Code Blue and Rapid Response
• Types of Patients• Type of Event• Patient Disposition
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17-Qtr 2 17-Qtr 3 17-Qtr 4 18-Qtr 1 Total
Inpt 21 12 18 13 64
Outpt 11 13 22 12 58
Employee 8 9 6 14 37
Visitor 3 4 6 2 15
Incorrect Calls 0 0 0 0 0
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200N
um
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Code Blue Response: Types of Patients
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17-Qtr 2 17-Qtr 3 17-Qtr 4 18-Qtr 1 TOTAL
Arrest 5 2 1 3 11
Acute Emergency 10 9 18 17 54
Stable Event 28 27 33 21 109
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Code Blue Response: Type of Event
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17-Qtr 2 17-Qtr 3 17-Qtr 4 18-Qtr 1 TOTAL
Transfer to ICU 14 7 11 11 43
Transfer to OSH 8 10 18 14 50
Remained on Unit 14 13 12 3 42
Expired 1 0 0 1 2
Released 2 1 3 3 9
Other 4 7 8 9 28
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Code Blue Response: Patient Disposition
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17-Qtr 2 17-Qtr 3 17-Qtr 4 18-Qtr 1 Total
ICU 11 8 5 8 32
Unit/Other 1 0 1 0 2
Remained on Unit 14 13 24 10 61
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Rapid Response Team: Patient Disposition
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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
C/T Ratio CC C/T Ratio Goal
(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.)
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Transfusion Reactions by Class
Anaphylactic and Other Febrile, Nonhemolytic Hemolytic, Septic, Anaphylactoid, and TRALI
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sUnacceptable Blood Bank Specimens
Percent specimens with collection problems CC Threshold
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Clinical Documentation• Medical Record Completeness
• Delinquent Records• “Agent for” Countersignature Adherence• Unacceptable Abbreviation Use
• Accuracy of Coding
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% r
eco
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inq
uen
t af
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Delinquent Records(>30 days post discharge)
Joint Commission Benchmark Delinquent Records
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% v
erb
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rder
s si
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in 7
2 h
ou
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"Agent for" Orders Countersignature Adherence
% of Compliance CC Goal
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% a
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se o
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bre
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“Do Not Use” Abbreviation Adherence
Compliance with Abbreviation Use CC Goal
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% a
ccu
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cod
ing
Accuracy of Record Coding
Accuracy of Coding CC Goal
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Employee Safety • Occupational Injury and Illness
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Comparison of the Number and Types of Recordable Occupational Injuries and Illnesses Cases Among CC Employees (2010 – 2017)
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M/S Trauma
Wounds
Ergonomic
Allergy
Other*
Burns
M/S Trauma: Musculoskeletal Trauma
*Other: Emotional, Inhalation, Communicable Exposure
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OSHA Recordable Occupational Injury and Illnesses CasesJan 1, 2017 - March 31, 2018
TRC ORC DAFW DJTR DART
TRC: Total Recordable Cases
ORC: Other Recordable Cases
DAFW: Days Away From Work
DJTR: Days Job Transfer, Restriction
DART: DAFW + DJTR
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47%
16%
6%
31%
Percent of Occupational Injuries and Illnesses Jan 1, 2018 - March 31, 2018 n=32
Musculoskeletal Wounds Burn Other
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TRC ORC DAFW DJTR DART
Cas
e In
cid
ence
Rat
e Occupational Injury and Illness Incidence Case Rates for Hospitals Nationwide in 2016
Compared with Incidence Case Rates for the NIH Clinical Center in 2017
US Hospitals CC