QUALITY/PRACTICE DASHBOARD
Action Items from 7/14/11
Jason clean up list and send back out or copy to wiki
Get existing reports before next meeting
Jason and Patricia will meet to go over excel spreadsheet
Contact Mike Maas and get financial report
Contact Rob McLean for ER report
Contact Pitcher for inpatient report
Consider discussing role with Worsham
Agenda for next meeting 8/4/11 at 1PM:
have reports from each source
review list of wanted measures
|
Practice |
Relevance Rank (2-6) |
Potential Source |
* |
Number of admits/discharges per day/week/month |
2 |
Jennifer's replacement |
* |
Length of Stay (omitting patients with LOS> 15 or 30 days) |
2 |
Jennifer's replacement |
|
Percentage of patient discharges after noon |
2 |
|
* |
Average daily census |
2 |
Jennifer's replacement |
|
ER Boarding Tme |
3 |
|
* |
Number of patients with LOS > 14 days |
3 |
Jennifer's replacement |
* |
ED consult to admit order time |
|
Robb McLean |
|
Coding levels - 231/232/233 etc. |
4 |
|
|
RVUs for group by week/month/quarter |
4 |
|
|
Delinquent charts |
6 |
|
|
Days from discharge to discharge summary |
6 |
|
|
Active research projects/pilots (number or participation rate) |
6 |
|
|
Case Mix Index |
|
|
|
|
|
|
|
|
|
|
|
Quality |
|
|
* |
VTE prophylaxis rate |
2 |
Allison Burnett |
* |
Observed/Expected Mortality |
2 |
Jim Little |
* |
Penumovax/Fluvax rates (4west/5west) |
2 |
Cathy Jaco/Quality |
* |
30 Day Readmission rate (by age, medicare status) |
|
Cathy Jaco/Quality or Quality and Safety Director |
* |
Press Ganey Scores from 4West/5West |
3 |
Cathy Jaco/Quality |
|
New MRSA/C Diff/Line infections rates |
3 |
|
* |
Hand Washing rate (4west/5west) |
3 |
Cathy Jaco/Quality |
|
Foley Catheter use > 48 hours |
3 |
|
|
Glycemic control |
4 |
|
|
Falls (per week, month, etc.) |
4 |
|
|
VTE appropriateness rate |
5 |
|
|
VTE order set utilization rate |
5 |
|
|
ICU transfer rate |
6 |
|
|
ISS only rate |
6 |
|
|
|
|
|
|
Education |
|
|
|
Shelf exam scores (average) |
2 |
|
* |
Phase 1, Phase 2 tutorials and lectures given |
2 |
FAD forms |
* |
Shelf exam fail rates |
3 |
Betty Chang |
* |
Resident reviews (quantitative |
4 |
Betty Chang |
* |
Medical student reviews (quantitative) (rotation vs faculty) |
4 |
Ed Fancovic |
|
Grand rounds attendance rate |
4 |
|
|
Morning rounds attendance rate |
4 |
|
|
Board pass rate |
5 |
|
|
In-service exam scores |
5 |
|
|
Participation in TED series |
6 |
|
|
|
|
|
Sources
Census levels from Quality (deran)
LOS
Mike's Financial reports
ER reports
O/E
Inpatient Medicine Leadership reports
SMITE report, VTE, glycemic control
VTE Prophylaxis
Process:
Appropriate Prophylaxis Rate; Order Set Utilization
Outcomes:
Preventable VTE Occurance rate per 10,000 patient days
Glycemic Control
Process:
Treatment Failure Rate, order set utilization, insulin usage percentages, Sliding scale only percent
Outcomes:
Percent patient days CBGs >300, Percent patient days CBGs <70, Mean CBG by patient day, Percentage patient days 70-180
Care Transitions
Process:
Coleman Care Transtiions Measure (CTM-3) CTM-3.pdf CTM-3-SCORING.pdf, DC Summary Quality, Notification of PCP
Outcomes:
readmission rates, press ganey scores on discharge questions
Infection Control
Process:
Handwashing rates; Foley cathters > 48 hrs/1000 pt days; VRE infections/1000 pt days, MRSA infections/1000 pt days; MRSA ASC rates; VAP rates; immunization rates among staff/physcians; pneumovax rates of pts
Outcomes:
Central line infection, C. diff, MRSA rates
General
Process:
transfers to ICU; average time in ED before admission; falls rates; Press-Ganey scores (overall satuisfaction, would you recommend?)
Outcomes:
mortality rate; autopsy rate;
PRACTICE DASHBOARD
Number of admissions/discharges
Census levels for each team
Number of days on "Code-purple"
Percentage of patients discharged after 12 noon
Ave LOS (without pts >30 days)
Pts currently on service who have been in hospital >30 days
Number of learners on service
PALS calls/transfers
Average days from discharge to dictated summary
Delinquent charts
Coding levels
RAU's billed by hospitalists
List of active research protocols recruiting patients
Education
FrontPage
Comments (0)
You don't have permission to comment on this page.