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CLINICAL AND SAFETY PERFORMANCE METRICSExecutive Dashboard
NIH Clinical CenterOctober 2019
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Patients’ Perceptions• Overall Hospital Rating• Would you Recommend the NIH CC?
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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
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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
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
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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
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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
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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
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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
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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
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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
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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
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Nursing Quality Metrics • Falls• Pressure Injury• Medication Administration Barcoding
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0
0.5
1
1.5
2
2.5
3
Q3 CY 2018 Q4 CY 2018 Q1 CY 2019 Q2 CY 2019 Q3 CY 2019
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
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0
1
2
3
4
5
6
Q3 CY 2018 Q4 CY 2018 Q1 CY 2019 Q2 CY 2019 Q3 CY 2019
% 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
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90%
91%
92%
93%
94%
95%
96%
97%
98%
99%
100%
Q3 CY 2018 Q4 CY 2018 Q1 CY 2019 Q2 CY 2019 Q3 CY 2019
% B
arco
de U
se
Medication Administration Barcode Use
Clinical Center Rate Goal
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Emergency Response• Code Blue and Rapid Response
• Types of Patients• Type of Event• Patient Disposition
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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"
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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
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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
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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
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Blood and Blood Product Use• Crossmatch to Transfusion (C:T) Ratio• Transfusion Reaction by Class• Unacceptable Blood Bank Specimens
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0.00
0.50
1.00
1.50
2.00
2.50
Q3 CY 2018 Q4 CY 2018 Q1 CY 2019 Q2 CY 2019 Q3 CY 2019
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
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0.0%
0.1%
0.2%
0.3%
0.4%
0.5%
0.6%
Q3 CY 2018 Q4 CY 2018 Q1 CY 2019 Q2 CY 2019 Q3 CY 2019
Perc
ent o
f Tra
nsfu
sions
Transfusion Reactions by Class
Anaphylactic Other Febrile, Nonhemolytic Hemolytic, Septic, Anaphylactoid, and TRALI
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0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
Q3 CY 2018 Q4 CY 2018 Q1 CY 2019 Q2 CY 2019 Q3 CY 2019
Perc
ent U
nacc
epta
ble
Spec
imen
s
Unacceptable Blood Bank Specimens
% Specimens with Collection Problems CC Threshold
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Clinical Documentation• Medical Record Completeness
• Delinquent Records• “Agent for” Countersignature Adherence• Unacceptable Abbreviation Use
• Accuracy of Coding
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0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Q3 CY 2018 Q4 CY 2018 Q1 CY 2019 Q2 CY 2019 Q3 CY 2019
% re
cord
s del
inqu
ent a
fter
30
days
Delinquent Records(>30 days post discharge)
% Records Delinquent Joint Commission Benchmark
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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
% v
erba
l ord
ers s
igne
d in
72
hour
s
"Agent for" Orders Countersignature Compliance
% of Compliance CC Goal
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75%
80%
85%
90%
95%
100%
Q3 CY 2018 Q4 CY 2018 Q1 CY 2019 Q2 CY 2019 Q3 CY 2019
% a
ppro
pria
te u
se o
f abb
revi
atio
ns"Do Not Use" Abbreviation Adherence
Compliance with Abbreviation Use CC Goal
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q3 CY 2018 Q4 CY 2018 Q1 CY 2019 Q2 CY 2019 Q3 CY 2019
% a
ccur
acy
of co
ding
Accuracy of Record Coding
Accuracy of Coding CC Goal
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Employee Safety • Occupational Injury and Illness
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0
5
10
15
20
25
30
35
40
Q2 CY 2018 Q3 CY 2018 Q4 CY 2018 Q1 CY 2019 Q2 CY 2019
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)
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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