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Sample Quality Dashboard Excel

The hospital quality dashboard shows performance on key quality indicators for various departments in 2018. Several metrics were below benchmarks for patient safety such as 30-day readmission rates, fall risk assessments, hospital acquired infections and pressure ulcers. Staffing was also an issue as employee turnover and workplace injuries exceeded targets. Overall the data indicates opportunities for improvement in patient outcomes and experience as well as workplace safety.

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346 views10 pages

Sample Quality Dashboard Excel

The hospital quality dashboard shows performance on key quality indicators for various departments in 2018. Several metrics were below benchmarks for patient safety such as 30-day readmission rates, fall risk assessments, hospital acquired infections and pressure ulcers. Staffing was also an issue as employee turnover and workplace injuries exceeded targets. Overall the data indicates opportunities for improvement in patient outcomes and experience as well as workplace safety.

Uploaded by

s
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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____________ Hospital Quality Dashboard 2018

Dashboard Key: Green – Indicates performance Meets or exceeds benchmark


Yellow – Indicates performance is within 5 points (%) of benchmark
Red - Indicates performance is outside of benchmark by greater than 5
points (%)

INDICATOR Jan Feb Mar Apr May June July


ACUTE CARE

Inpatient Admissions

30 day readmission rate for “All-Cause”

Benchmark: <20%

Fall Risk Assessment on Admission


Completed
Benchmark: 95%

Fall with injury incidence (per 1,000 patient


days)
Skin Risk Assessments completed upon
admission rate
Benchmark: 95%

Hospital Acquired Pressure Ulcer Incidence


(per 1,000 patient days)
Benchmark:0

Average length of Stay in days

Inpatient Discharges per month

SWING BED UTILIZATION

Swing bed days per month

Average LOS in days

Skin Risk Assessments completed upon


admission rate
Benchmark:95%
Pressure Ulcer Incidence (per 1,000 patient
days)
Fall Risk Assessment on Admission
Completed
Benchmark: 95%

Fall with injury incidence (per 1,000 patient


days)
Benchmark: 1

EMERGENCY DEPARTMENT

Total number of ED visits

Total number of AMA/LWBS/LWCC

72 Hour Return to ED rate for “All-Cause”

Emergency Department Transfer Rate

AMI – Median time to fibrinolysis

Benchmark: 30 minutes

AMI-Median time to transfer to another


facility for Acute Coronary Intervention
Benchmark:

AMI – Median time to ECG

Benchmark:

Chest Pain-ASA at arrival

Benchmark: 95%

Stroke-Median time from arrival to ED to


CT/MRI
Benchmark:

Stroke-CT/MRI results for stroke patients


with scan interpretation
Benchmark:< 45 minutes
Throughput: Median time from arrival to ED
to Departure from ED - overall
Throughput: Median time from arrival to ED
for departure from ED for Psych patients
Throughput: Door to Diagnostic Evaluation
by a Qualified Medical Professional
Goal: 30 minutes

Median Time to Pain Management for Long


Bone Fracture
Benchmark: 60 minutes

Number of Cardiopulmonary Arrests per


month (facility wide)
Survival rate of cardiopulmonary arrests

QUALITY

Patient Grievances

Benchmark: 2 per month

Influenza Vaccination Coverage Healthcare


Personnel (annual report to National
Healthcare Safety Network: May)
Benchmark: 98%

Adverse Drug Events

Benchmark: 0

INFECTION PREVENTION

Healthcare Acquired Infection Occurrence


(per 1,000 patient days) ACUTE CARE
Benchmark: <2 per month

Healthcare Acquired Infection Occurrence


(per 1,000 patient days) SWING BEDS
Benchmark: <2 per month

CLBSI (Central Line Bloodstream Infections) –


Hospital Acquired - Acute Care
Benchmark: 0
CAUTI (Catheter Associated Urinary Tract
Infections) – Hospital Acquired - Acute Care
Benchmark: 0

CDI (Clostridium difficile infections) Hospital


Acquired - Acute Care
Benchmark: 0

SSI (Surgical Site Infections) – Total Knee

Benchmark: 0

SSI (Surgical Site Infections) – Total Hip

Benchmark: 0

Postoperative DVT (Deep Vein Thrombosis)

Benchmark: 0

Bloodborne Pathogen Exposures

Benchmark: 0

SURGERY

Total number of surgeries

Total number of Procedures

Total number of return to surgery

Benchmark: 0

SCIP (Surgical Care Improvement Project)


Compliance
a.    Normothermia

b.    Timing and Discontinuation of


Prophylactic Antibiotics
i.            Preoperative: antibiotic within one
hour of surgical incision
ii.           Postoperatively: prophylactic
antibiotics discontinued within 24 hours
after surgery
c.    Selection of Antibiotics (as
recommended for total knee/hip operations)
d.    Glucose Control

e.    Timing of Foley catheter removal post


surgery
f.     Patients on Beta Blocker Therapy
receive Beta Blocker during Perioperative
Period
g.    Appropriate Venous Thromboembolism
prophylaxis within 24 hours prior to and 24
hours after surgery
HUMAN RESOURCES

Employee Turnover

Benchmark: <20%

Worker Injuries per month

Benchmark: 1 per month

Loss Time associated with worker injury

Benchmark: 2 per month

Cost related to worker injuries

Workplace Violence Events

Benchmark: 0

Laboratory

# of blood units transfused

% of records meeting blood


administration/appropriateness criteria
Benchmark: 95%
hmark
of benchmark
y greater than 5

Aug Sept Oct Nov Dec YTD 2017

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