Page 361 - CEO Orientation

DRAFT SEPTEMBER 25, 2017

Network Safety & Quality at a Glance
Q3 2017/18

Safety & Quality Indicators
Providence St. Joseph's St. Michael's

Indicator Q1 Actual Q2 Actual Q3 Actual Q1 Actual Q2 Actual Q3 Actual Q1 Actual Q2 Actual Q3 Actual
PUBLICALY REPORTED SAFETY INDICATORS
Hand Hygiene Compliance 96.7% 97.3% 95.0% 67.9% 42.5% 52.2% 76.7% 79.9% 78.1%
C.Difficile infections ( reported same way by HQO) 0.15 0.10 0.14 0.24 0.21 0.27 0.46 0.31 0.28
MRSA Bacteremia Rate (per 1000 patient days) 0.00 0.00 0.00 0.00 0.03 0.00 0.20 0.00 0.00
VRE Bacteremia Rate (per 1000 patient days) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Surgical Safety Checklist Compliance (also an Accreditation Canada
ROP) n/a n/a n/a 100% 100% 100% 99.3% 99.9% 99.5%
NEVER EVENTS & CRITICAL INCIDENTS
Number of never events 0 0 2 11 6 12 1 0 0
Number of critical incidents 9 12 1 1 0 1 5 2 3
REQUIRED ORGANIZATIONAL PRACTICES (ROPs)
Falls risk assessment NA NA NA 53.66% 45.71% 51.35% 79.0% 79.0% 75.0%
Harm Fall Rate (PHC)
Fall Rate (SJHC & SMH) 1.6 1.3 1.1 6.79 6.59 5.62 4.46 4.38 3.95
VTE prophylaxis assessment rate n/a n/a n/a 93.45% 93.77% 92.97% 88.0% 88.0% 86.0%
Post-admit DVT and PE rate n/a n/a n/a NA NA NA 3.01 2.07 3.33
Pressure injuries - Hospital 10 8 4 9.13% 9.45% 12.20% NA NA NA
Documented medication reconciliation/BPMH on admission NA NA NA 71.8% 72.6% 72.8% 76.0% 74.7% 79.1%

n/a = not applicable NA = Not Available