Page 111 - Flipbook January Board

Robert Packer Hospital

Effectiveness
National and Top Internal
Quality Metrics FY19 TD Q4 FY19 Q3 FY19 Q2 FY19 Q1 FY19 FY18 Q4 FY18 Q3 FY18 Q2 FY18 Q1 FY18 FY17 FY16 FY 15
Decile Index Target
RPH Mortality Index to Expected (U.S. National) 1.0 0.77 0.87 0.88 0.85 0.92 0.76 0.83 0.91 1.02 1.16 0.90
Internal
Readmission Rate (AMI, CHF, PN, COPD, THA/TKA) National Rate 3 FY19 TD Q4 FY19 Q3 FY19 Q2 FY19 Q1 FY19 FY18 Q4 FY18 Q3 FY18 Q2 FY18 Q1 FY18 FY17 FY16 FY 15
Target
Readmissions after treatment for AMI 16.0% 12.2% 10.4% 9.8% 6.5% 9.0% 12.7% 11.0% 10.4% 13.5% 15.3%
Readmissions after treatment for Heart Failure 21.7% 19.0% 18.4% 19.8% 22.7% 18.6% 24.4% 12.3% 21.6% 22.2% 21.1%
Readmissions after treatment for Pneumonia (PN) 16.7% 10.1% 8.6% 13.9% 9.6% 17.5% 14.5% 12.2% 16.0% 18.4% 16.4%
Readmissions after treatment for Chronic Obstructive Pulmonary Disease 19.6% 10.1% 8.9% 10.8% 5.0% 14.8% 8.2% 13.8% 15.4% 20.1% 20.8%
(COPD)
Readmissions after treatment for Total Hip/Total Knee Replacement 4.2% 1.4% 0.6% 2.5% 2.3% 1.3% 4.3% 2.5% 4.6% 3.7% 2.6%
Readmissions after treatment for COPD, AMI, CHF, PN, THA/TKA 9.0% 10.3% 9.5% 10.8% 10.0% 11.4% 12.8% 8.9% 12.9% 14.5% 14.3%
Safety

Top Decile
HAI's National Rate 1 FY19 TD Q4 FY19 Q3 FY19 Q2 FY19 Q1 FY19 FY18 Q4 FY18 Q3 FY18 Q2 FY18 Q1 FY18 FY17 FY16 FY 15
Benchmark
Catheter Associated UTI (CAUTI) (Rate per 1,000 Catheter Days/Total 2.2 0 1.55/ 4 1.55/ 4 0.79/ 9 0.37/ 1 0.34/ 1 1.51/ 4 0.96/ 3 0.51/ 7 0.63/ 9 0.43/ 6
Infections)
Central Line Associated Bacteremia (CLABSI) 1.4 0 0.92/ 2 0.92/ 2 0.87/ 7 1.44/ 3 0/ 0 0.94/ 2 1/ 2 0.32/ 3 0.82/ 8 0.3/ 3
(Rate per 1,000 Central Line Days/Total Infections)
Clostridium Difficile Infection( C-Diff) 6.07
(Rate per 10,000 Patient Days/Total Infections) N/A *Internal 6.88/ 19 7.86/ 13 7.04/ 44 7.1/ 11 6.18/ 10 5.91/ 9 8.99/ 14 6.84/ 43 6.74/ 44 6.99/ 47
Goal
Internal
HAI - Hand Hygiene Compliance - nGage FY19 TD Q4 FY19 Q3 FY19 Q2 FY19 Q1 FY19 FY18 Q4 FY18 Q3 FY18 Q2 FY18 Q1 FY18 FY17 FY16 FY 15
Target
% Compliance RPH 80.2% 75.4% 76.1% 72.9% 74.6% 72.9% 73.0% 71.1% 70.5% 70.3% 65.3%

Patient Falls FY19 TD Q4 FY19 Q3 FY19 Q2 FY19 Q1 FY19 FY18 Q4 FY18 Q3 FY18 Q2 FY18 Q1 FY18 FY17 FY16 FY 15
Patient Falls with Injury RPH 20 14 33 6 6 14 10 34 45 43
Timeliness

Top Decile Internal
Flow (Minutes) FY19 TD Q4 FY19 Q3 FY19 Q2 FY19 Q1 FY19 FY18 Q4 FY18 Q3 FY18 Q2 FY18 Q1 FY18 FY17 FY16 FY 15
Benchmark Target
*Median Times*
RPH Door to Door (Outpatient)*CMS Reported Measure* 90 134 179 179 177 185 168.5 177 180 155 137 132
RPH Door to Floor *CMS Reported Measure* 166 253 346 346 323 339 378.5 305 301.5 274 266 310
Internal Measures
RPH Bed Request to ED Departure(Median Times) 55 73 73 67 70 69 62 58 55 51 58
RPH ED Hold > 6 Hours <18% 16.9% 16.9% 15.4% 15.3% 17.7% 14.3% 14.2% 9.8% 8.6% 11.9%
RPH IP Average LOS 4.35 4.26 4.26 4.24 4.12 4.38 4.23 4.24 4.41 4.36 4.43
RPH Obs % LOS < 20 Hours (Admit Order to DC) ≥45% 40.3% 40.3% 45.8% 42.4% 46.2% 44.3% 49.8% 38.8% 43.3% 44.7%
RPH Discharges By 11AM ≥10% 9.3% 9.3% 9.7% 12.2% 10.8% 7.4% 8.6% 8.6% 8.7% 9.0%
RPH IP Discharges Within 60 Minutes of D/C Order ≥25% 23.9% 23.9% 21.8% 22.7% 22.2% 20.0% 22.1% 23.3% 23.7% 23.2%
RPH Obs Discharges Within 60 Minutes of D/C Order ≥45% 40.2% 40.2% 41.5% 40.7% 40.6% 42.9% 41.8% 39.3% 35.9% 35.5%
RPH SP % Of Patients Discharged < 2 Hrs After Leaving the OR ≥55% 68.9% 68.9% 63.0% 64.7% 62.2% 58.9% 66.2% 53.0% 42.3% 41.8%
Patient Centeredness