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Census levels from Quality (deran)


Mike's Financial reports

ER reports


Inpatient Medicine Leadership reports

SMITE report, VTE, glycemic control


VTE Prophylaxis


Appropriate Prophylaxis Rate; Order Set Utilization


Preventable VTE Occurance rate per 10,000 patient days


Glycemic Control


Treatment Failure Rate, order set utilization, insulin usage percentages, Sliding scale only percent


Percent patient days CBGs >300, Percent patient days CBGs <70, Mean CBG by patient day, Percentage patient days 70-180


Care Transitions


Coleman Care Transtiions Measure (CTM-3) CTM-3.pdf CTM-3-SCORING.pdf, DC Summary Quality, Notification of PCP


readmission rates, press ganey scores on discharge questions


Infection Control


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


Central line infection, C. diff, MRSA rates 




transfers to ICU; average time in ED before admission; falls rates; Press-Ganey scores (overall satuisfaction, would you recommend?)


mortality rate; autopsy rate;




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











Quality Dashboard

Page history last edited by Jason Cohen 9 years, 6 months ago




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    
* 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  
  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  

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