clinical performance and employee safety metrics (october...

CLINICAL AND SAFETY PERFORMANCE METRICSExecutive Dashboard

NIH Clinical CenterOctober 2019

Patients’ Perceptions• Overall Hospital Rating• Would you Recommend the NIH CC?

50

55

60

65

70

75

80

85

90

95

100

Q3 CY 2018 Q4 CY 2018 Q1 CY 2019 Q2 CY 2019 Q3 CY 2019

Perc

ent P

ositi

ve R

espo

nse

Overall Hospital Rating

Overall Rating of NIH CC - Inpatient Overall Rating of NIH CC - Outpatient

CMS HCAHPS Benchmark (Average) NRC Benchmark (Average)

Q3 CY 2019 data collection in progress

50

55

60

65

70

75

80

85

90

95

100


Perc

ent P

ositi

ve R

espo

nse

Would You Recommend the NIH CC?

Would Recommend NIH CC - Inpatient Would Recommend NIH CC - Outpatient

CMS HCAHPS Benchmark (Average) NRC Benchmark (Average)

Q3 CY 2019 data collection in progress

Infection Control Metrics • Hand Hygiene• Central-Line Associated Bloodstream Infections

• Whole-house• Intensive Care Unit

• Catheter Associated Urinary Tract Infections• Intensive Care Unit• Surgical Oncology

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2018-Q2 2018-Q3 2018-Q4 2019-Q1 2019-Q2

Perc

ent A

dher

ence

Hand Hygiene Compliance

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2018-Q2 2018-Q3 2018-Q4 2019-Q1 2019-Q2

Infe

ctio

ns p

er 1

,000

cath

eter

day

sWholehouse Central-Line Associated Bloodstream Infection (CLABSI) Rate

0.00

0.20

0.40

0.60

0.80

1.00

1.20

2018-Q2 2018-Q3 2018-Q4 2019-Q1 2019-Q2

Infe

ctio

ns p

er 1

,000

cath

eter

day

s

ICU Central-Line Associated Bloodstream Infection (CLABSI) Rate

ICU CLABSI Rate NHSN ICU Benchmark

2013 CDC National Healthcare Safety Network (NHSN) Benchmark: Critical Care Units, Medical/Surgical -major teaching mean 1.1

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

2018-Q2 2018-Q3 2018-Q4 2019-Q1 2019-Q2

Infe

ctio

ns p

er 1

,000

fole

y da

ysICU Catheter-Associated Urinary Tract Infections (CAUTI) Rate

ICU CAUTI Rate NHSN ICU Benchmark

2013 CDC National Healthcare Safety Network (NHSN) Benchmark: Critical Care Units, Medical/Surgical -major teaching mean 2.7

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

2018-Q2 2018-Q3 2018-Q4 2019-Q1 2019-Q2

Infe

ctio

ns p

er 1

,000

fole

y da

ys

Surgical Oncology Catheter-Associated Urinary Tract Infections (CAUTI) Rate

Surgical Oncology CAUTI Rate NHSN Medical/Surgical Benchmark

2013 CDC National Healthcare Safety Network (NHSN) Benchmark: Inpatient Wards, Medical/Surgical mean 1.3

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

2018-Q2 2018-Q3 2018-Q4 2019-Q1 2019-Q2

Infe

ctio

ns p

er 1

00 p

roce

dure

sSurgical Site Infections (SSI) Rate

SSI Rate 2018 Clinical Center Average

Nursing Quality Metrics • Falls• Pressure Injury• Medication Administration Barcoding

0

0.5

1

1.5

2

2.5

3


Falls

per

1,0

00 p

atie

nt d

ays

Inpatient Falls Rate

Quarterly Rate NDNQI Benchmark Inpatient Falls with Injury

Q3 NDNQI Benchmark Pending

NDNQI benchmark for Total Falls Rate Only

0

1

2

3

4

5

6


% o

f sur

veye

d pa

tient

s with

pre

ssur

e in

jury

Pressure Injury Prevalence

Quarterly Rate

Q3 NDNQI Benchmark

Pending

NDNQI Benchmark for Total Pressure Injury Rate only

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%


% B

arco

de U

se

Medication Administration Barcode Use

Clinical Center Rate Goal

Emergency Response• Code Blue and Rapid Response

• Types of Patients• Type of Event• Patient Disposition

Q4 CY 2018 Q1 CY 2019 Q2 CY 2019 Q3 CY 2019 TotalInpt 12 10 23 21 66Outpt 14 13 21 14 62Employee 10 12 13 7 42Visitor 6 9 2 5 22Incorrect Calls 0 0 0 0 0

0

50

100

150

200

250N

umbe

rCode Blue Response: Types of "Patients"

Q4 CY 2018 Q1 CY 2019 Q2 CY 2019 Q3 CY 2019 TOTALBrain Code 6 6Arrest 2 0 0 1 3Acute Emergency 7 12 34 19 72Stable Event 33 32 25 21 111

0

50

100

150

200

250N

umbe

rCode Blue Response: Type of Event

Q4 CY 2018 Q1 CY 2019 Q2 CY 2019 Q3 CY 2019 TOTALTransfer to ICU 10 6 17 17 50Transfer to OSH 11 20 16 12 59Remained on Unit 10 11 18 11 50Expired 2 0 0 1 3Released 3 1 1 2 7Other 6 6 7 4 23

0

50

100

150

200

250

Num

ber

Code Blue Response: Patient Disposition

Q4 CY 2018 Q1 CY 2019 Q2 CY 2019 Q3 CY 2019 TotalICU 5 5 7 9 26Unit/Other 4 1 1 2 8Remained on Unit 3 13 8 31 55

0

10

20

30

40

50

60

70

80

90

100N

umbe

rRapid Response Team: Patient Disposition

Blood and Blood Product Use• Crossmatch to Transfusion (C:T) Ratio• Transfusion Reaction by Class• Unacceptable Blood Bank Specimens

0.00

0.50

1.00

1.50

2.00

2.50


Cros

smat

ch to

Tra

nsfu

sed

Uni

ts R

atio

Crossmatch to Transfusion (C/T) Ratio(The NIH CC goal is to have a C:T ratio of 2.0 or less. Monitoring this metric ensures that blood is not held unused in reserve when it

could be available for another patient.)

C/T Ratio CC C/T Ratio Goal

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%


Perc

ent o

f Tra

nsfu

sions

Transfusion Reactions by Class

Anaphylactic Other Febrile, Nonhemolytic Hemolytic, Septic, Anaphylactoid, and TRALI

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%


Perc

ent U

nacc

epta

ble

Spec

imen

s

Unacceptable Blood Bank Specimens

% Specimens with Collection Problems CC Threshold

Clinical Documentation• Medical Record Completeness

• Delinquent Records• “Agent for” Countersignature Adherence• Unacceptable Abbreviation Use

• Accuracy of Coding

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%


% re

cord

s del

inqu

ent a

fter

30

days

Delinquent Records(>30 days post discharge)

% Records Delinquent Joint Commission Benchmark

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


% v

erba

l ord

ers s

igne

d in

72

hour

s

"Agent for" Orders Countersignature Compliance

% of Compliance CC Goal

75%

80%

85%

90%

95%

100%


% a

ppro

pria

te u

se o

f abb

revi

atio

ns"Do Not Use" Abbreviation Adherence

Compliance with Abbreviation Use CC Goal

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% a

ccur

acy

of co

ding

Accuracy of Record Coding

Accuracy of Coding CC Goal

Employee Safety • Occupational Injury and Illness

0

5

10

15

20

25

30

35

40


Num

ber o

f Cas

es

Occupational Injuries and Illnesses for CC Employees

TRC ORC DAFW DJTR DART

TRC: Total Recordable Cases; ORC: Other Recordable Cases; DAFW: Days Away From Work; DJTR: Days Job Transfer, Restriction; DART: Days Away, Restricted or Transferred (DAFW + DJTR)

61.8%14.7%

5.9%

17.6%

Percent of Occupational Injuries and Illnesses April 1, 2019 - June 30, 2019 n= 34

Musculoskeletal Wounds Ergonomic Other

clinical performance and employee safety metrics (october...

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