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Greenville Health System
Quality and Safety Report
April 2013
G R E E NV IL L E H O S PIT AL S Y S T E M – U NIV E R S IT Y ME D IC AL C E NT E R Quality Dashboard
Calendar Years: 2010, & 2011
April 2013
Quarterly: CY 2012 & CY 2013
REPORT OF GREENVILLE HEALTH SYSTEM QUALTIY PERFORMANCE INDICATORS
CY10 CY 11 1st Qtr CY 12 2nd Qtr CY 12 3rd Qtr CY 12 4th Qtr CY 12 1st Qtr CY 13 Q UA L IT Y ME A SUR E CMS Value Based Purchasing CMS All Care Measures Mortality Rate Readmission Rate within 30 days National Patient Safety Goals – Process change Jan 11 AHRQ Culture of Safety Survey Reported Event Rate Events: Inpatient Falls See attached report
Events: Medication Errors See attached report
Events: With Harm Hand Hygiene Rate Surgical Site Infections Central-­‐Line Associated Bloodstream Infections Catheter-­‐Associated Urinary Tract Infection See attached report
At or Above Target
Below Target
Methicillin-­‐Drug-­‐Resistant Organisms No data available
• Report generated April 2013 G R E E NV IL L E H O S PIT AL S Y S T E M – U NIV E R S IT Y ME D IC AL C E NT E R Quality Dashboard
Q UA L IT Y ME A SUR E April 2013
Mos t R ec en t R es u lt T ar g et C om m en ts C MS V alu e Bas ed Pu r c h as in g C lin ic al Meas u r es 98.7%
≥ 98.0%
C om p os ite s core rep res en ts a roll -­‐u p of 1 2 clin ical m eas u res at G MH , G rMH , H MH an d PMH < 98.0%
T arg et bas ed on org an iz ation al g oal. D ata res u lt: A p r 1 2 – D ec 12 ≥ 93.0%
C MS A ll C ar e Meas u r es 95.3%
In clu d es inpatient m eas u res on ly for GMH , G rMH , H MH an d PMH . < 93.0%
T arg et bas ed on org an iz ation al g oal. D ata res u lt: D ec 1 2 ≤ 2.3%
Mor tality R ate 2.0%
> 2.3%
In p atien t in d icator for G MH , G rMH , H MH an d PMH . T arg et bas ed on 3M Severity –
A d j u s ted V alu e. D ata s ou rce: Prem ier. D ata res u lt: O ct 1 2 – D ec 12 R ead m is s ion R ate w ith in 3 0 d ay s ≤ 10.1%
9.3%
>10.1%
In p atien t in d icator for G MH , G rMH , H MH , an d PMH . T arg et bas ed on 3M Severity –
A d j u s ted V alu e. D ata s ou rce: Prem ier. D ata res u lt: O ct 1 2 – D ec 12 At or Above Target
Below Target
*Report generated April 2013 G R E E NV IL L E H O S PIT AL S Y S T E M – U NIV E R S IT Y ME D IC AL C E NT E R Quality Dashboard
Q UA L IT Y ME A SUR E April 2013
Mos t R ec en t R es u lt T ar g et C om m en ts Percen tag e m eetin g criteria p er q u arter. N ation al Patien t Safety G oals 88.5%
≥ 90.0%
< 90.0%
In clu d es GMH , G rMH , H H , PMH , R C PH , MIPH , N G H , Bru s h y C reek an d Su bacu te in p atien t facilities . D ata res u lt: O ct 1 2 – D ec 12 A H R Q C u ltu r e of Safety Su r v ey R ep or ted E v en t R ate 64.2%
≥ 67.0%
< 67.0%
29.3
≥ 40.18
< 40.18
≤ 3.18
E v en ts : In p atien t F alls 4.00
> 3.18
A n n u al s u rvey. T arg et bas ed on A H R Q com p arative d atabas e res u lts . D ata res u lt: A n n u al s u rvey con d u cted in A u g u s t 2 0 1 2 Sou rce: PSN Even t R ep ortin g Sys tem . T h e rate is calcu lated bas ed on th e n u m ber of even ts rep or ted p er 1 0 0 0 p atien t d ays . T arg et bas ed on 7 5 th p ercen tile from UH C com p arable s iz e facilities . D ata res u lt: O ct 1 2 – D ec 12 Sou rce: PSN Even t R ep ortin g Sys tem . T h e rate is calcu lated bas ed on th e n u m ber of in p atien t even ts rep orted p er 1 0 0 0 p atien t d ays T arg et bas ed on 7 5 th p ercen tile from UH C com p arable s iz e facilities . D ata res u lt: O ct 1 2 – D ec 12 • Report generated April 2013 G R E E NV IL L E H O S PIT AL S Y S T E M – U NIV E R S IT Y ME D IC AL C E NT E R Quality Dashboard
QUALITY MEASURE
April 2013
Mos t R ec en t R es u lt
Target
Comments
H an d H y g ien e ≥ 90%
91.9%
R es u lt for G H S is weig h t-­‐bas ed an d rep res en ts d ata from G MH , G rMH , H H , PMH , R C P, N G H , an d MIPH . < 90%
T arg et bas ed on org an iz ation al g oal. D ata res u lt: J an 1 3 -­‐ Mar 1 3 Su r g ic al Site In fec tion s C en tr al-­‐A s s oc iated Blood s tr eam In fec tion s C ath eter -­‐A s s oc iated Ur in ar y T r ac t In fec tion (C A U T I) See
attached
report
See
attached
report
See
attached
report
≤ Mean
T arg ets are bas ed on N H SN Pooled Mean . > Mean
≤ Mean
> Mean
≤ Mean
T arg ets are bas ed on N H SN Pooled Mean . In clu d es GMH , G rMH , H H , PMH facilities . G reer, Patewood , an d H illcr es t Mem orial H os p itals h ave n o C L A BSIs . T arg ets are bas ed on N H SN Pooled Mean for G MH A d u lt an d Ped iatric C ritical C are Un its . > Mean
In clu d es GMH , G rMH , H H , PMH facilities . • Report generated April 2013 Accreditations / Process /
Outcomes Measures
Accreditations
Core Measures / Value Based Purchasing
Mortality Rates
Readmission Rates
Accreditations
•  Joint Commission
– 
– 
– 
– 
2012: Full 3 Year Accreditation for All Hospitals
GHS Cancer Centers of the Carolinas – No Deficiencies
Primary Stroke Center (GMH)
CMS Issue … Unified vs. Separate Medical Staffs
•  Other Accreditations / Registries
– 
– 
– 
– 
CARF (Roger C. Peace Hospital)
American College of Surgeons Commission on Cancer
National Accreditation Program for Breast Centers
DHEC Level I Trauma Center (GMH)
Managed Care Designated
Centers of Excellence
•  Managed Care Centers of Excellence – Optum
–  Bariatrics for Hillcrest
•  Managed Care Centers of Excellence – BCBS
– 
– 
– 
– 
Knee/Hip for Greer and Patewood
Bariatrics for Hillcrest
Spine for GMH, Patewood
Cardiac for GMH
Core Measures
Inpatient and Outpatient: Jan 2012 – Dec 2012
Composite Perfect Composite Perfect YTD VBP Last Care Last Prior 12 Care Prior Domain Quarter Quarter Months 12 Months Score Greenville
Greer Hillcrest
Patewood
GHS
97.78%
98.95%
98.44%
99.65%
98.56%
94.59%
97.16%
96.84%
98.38%
96.04%
98.10%
99.11%
98.77%
99.65%
98.73%
94.96%
97.27%
97.29%
98.43%
96.25%
65.00%
82.00%
98.42%
85.71%
71.67%
Baptist Easley 99.42%
97.96%
99.50%
98.30%
90.00%
All Care Measures – Combined
Annual Composite Score: 98.7%
All Care Measure Score: 96.2%
INPATIENT AND OUTPATIENT MEASURES
Facility
Jan 12
Feb 12
Mar 12
Apr 12
May 12
Jun 12
Jul 12
Aug 12
Sep 12
Oct 12
Nov 12
Dec 12
Rolling 12
Months:
Jan 12Dec 12
Greenville Memorial
95.8%
95.0%
92.1%
96.7%
94.2%
95.6%
93.5%
97.0%
96.8%
95.7%
93.7%
94.3%
95.0%
Greer Memorial
98.5%
94.8%
97.1%
96.6%
97.4%
98.2%
99.1%
98.2%
96.2%
97.4%
97.9%
96.3%
97.3%
Hillcrest Memorial
98.9%
100.0%
95.5%
98.5%
95.9%
97.6%
96.1%
96.1%
98.6%
98.1%
96.9%
95.5%
97.3%
Patewood Memorial
98.1%
98.1%
99.2%
100.0%
96.8%
96.6%
97.7%
99.2%
100.0%
98.6%
97.3%
99.3%
98.4%
GHS
97.0%
96.0%
94.8%
97.5%
95.4%
96.5%
95.4%
97.5%
97.4%
96.8%
95.5%
95.7%
96.2%
Performing at or above FY11 Organizational target of 93.0%
• Report generated April 2013 All Care Measures – Inpatient
Annual Composite Score: 98.7%
All Care Measure Score: 95.9%
INPATIENT MEASURES
Facility
Jan 12
Feb 12
Mar 12
Apr 12
May 12
Jun 12
Jul 12
Aug 12
Sep 12
Oct 12
Nov 12
Dec 12
Rolling 12
Months:
Jan 12Dec 12
Greenville Memorial
95.1%
95.3%
91.0%
96.0%
93.6%
94.4%
92.1%
97.3%
96.8%
95.1%
92.7%
93.9%
94.4%
Greer Memorial
98.3%
94.7%
97.4%
96.3%
98.1%
97.9%
99.0%
98.1%
95.9%
97.1%
97.7%
96.0%
97.1%
Hillcrest Memorial
98.9%
100.0%
95.1%
100.0%
96.8%
97.0%
95.3%
96.9%
98.4%
97.9%
96.6%
94.9%
97.2%
Patewood Memorial
97.8%
97.9%
99.2%
100.0%
96.6%
96.0%
97.4%
99.2%
100.0%
98.5%
97.1%
99.1%
98.2%
GHS
96.6%
96.1%
94.4%
97.2%
95.3%
95.7%
94.7%
97.8%
97.4%
96.5%
95.0%
95.3%
95.9%
Performing at or above FY11 Organizational target of 93.0%
• Report generated April 2013 AMI
(Heart
Attack)
GHS Composite score: 99.5% GHS All Care Measure score: 98.3%
Acute Myocardial Infarction (AMI)
Greenville
Greer
Hillcrest
CMS Hospital
Quality Alliance
Oct 12 - Dec 12
Oct 12 - Dec 12
Oct 12 - Dec 12
Oct 11 - Sept 12
Num/
Den
Num/
Den
Percent
Num/
Den
Percent
Percent
SC
National
Average Average
Top
Performers
Aspirin at arrival
200/200 100.0%
0 patients
NA
1/1
100.0%
NA
NA
NA
Aspirin prescribed at discharge
192/194
99.0%
0 patients
NA
0 patients
NA
99%
99%
100%
37/38
97.4%
0 patients
NA
0 patients
NA
NA
NA
NA
178/181
98.3%
0 patients
NA
0 patients
NA
NA
NA
NA
0 patients
NA
0 patients
NA
60%
61%
100%
0 patients
NA
0 patients
NA
97%
95%
100%
0 patients
NA
0 patients
NA
98%
98%
100%
ACE inhibitor or ARB for left ventricular
systolic dysfunction
Beta-blocker prescribed at discharge
Fibrinolytic therapy received within 30
0 patients
NA
minutes of hospital arrival
Primary PCI received within 90 minutes of
47/47 100.0%
hospital arrival
Statin prescribed at discharge
CMS Public Report: June 11
AMI
CMS 30-Day Mortality
AMI
CMS Readmission Rate
191/193
99.0%
Jul 08 - Jun 11
Jul 08 - Jun 11
Jul 08 - Jun 11
Jul 08 - Jun 11
17.3%
14.5%
No different than
National Rate
No different than
National Rate
Number of cases
too small
15.5%
U.S. National Rate
Number of cases
too small
19.7%
U.S. National Rate
15.9%
Better than
National Rate
Performing at or above Organizational target of 98%.
Number of cases
too small
• Report generated April 2013 CHF
(Heart
Failure)
GHS Composite score: 99.2% GHS All Care Measure score: 98.3%
Heart Failure (HF)
Discharge Instructions
LVF Assessment
ACEI/ARB For LVSD
CMS Public Report: June 11
Heart Failure
CMS 30-Day Mortality
Heart Failure
CMS Readmission Rate
Greenville
Greer
Hillcrest
CMS Hospital
Quality Alliance
Oct 12 - Dec 12
Oct 12 - Dec 12
Oct 12 - Dec 12
Oct 11 - Sept 12
Num/
Den
Percent
Num/
Den
Percent
Num/
Den
Percent
SC
AVG
NAT AVG
Top
Performer
137/138
99.3%
20/20
100.0%
11/11
100.0%
95%
93%
100%
29/29
100.0%
16/16
100.0%
99%
99%
100%
7/7
100.0%
2/2
100.0%
98%
97%
100%
165/165 100.0%
53/55
96.4%
Jul 08 - Jun 11
Jul 08 - Jun 11
Jul 08 - Jun 11
12.6%
11.2%
11.7%
No different than
National Rate
No different than
National Rate
No different than
National Rate
18.5%
21.8%
24.2%
Better than
National Rate
No different than
National Rate
No different than
National Rate
Performing at or above Organizational target of 98%.
Jul 08 - Jun 11
11.6%
U.S. National Rate
24.7%
U.S. National Rate
Performing below Organizational target of 98%.
• Report generated April 2013 Pneumonia
GHS Composite score: 98.4% GHS All Care Measure score: 97.4%
Greenville
Greer
Hillcrest
CMS Hospital
Quality Alliance
Oct 12 - Dec 12
Oct 12 - Dec 12
Oct 12 - Dec 12
Oct 11 - Sept 12
Pneumonia (PN)
Num/
Den
Percent
Num/
Den
Percent
Num/
Den
Percent
SC
AVG
NAT AVG
Top
Performer
Blood cultures performed within 24 hours
of hospital arrival- pts transferred or
admitted to the ICU
48/49
98.0%
16/16
100.0%
11/11
100.0%
NA
NA
NA
131/133
98.5%
42/42
100.0%
33/34
97.1%
98%
97%
100%
67/67
100.0%
29/26
100.0%
28/28
100.0%
96%
95%
100%
Blood cultures performed in the ED prior
to initial antibiotic received in the hospital
Initial antibiotic selection in
immunocompetent patient
CMS Public Report: June 11
Jul 08 - Jun 11
13.0%
CMS 30-Day Mortality
No different than
National Rate
16.7%
18.4%
16.8%
CMS Readmission Rate
No different than
National Rate
No different than
National Rate
No different than
National Rate
Performing at or above Organizational target of 98%.
Jul 08 - Jun 11
Jul 08 - Jun 11
Jul 08 - Jun 11
11.9%
11.3%
No different than
National Rate
No different than
National Rate
12.0%
U.S. National Rate
18.5%
U.S. National Rate
Performing below Organizational target of 98%.
• Report generated April 2013 Surgical
Care
Improvement
Project
GHS Composite score: 97.6% GHS All Care Measure score: 94.3%
Surgical Care Improvement Project
(SCIP) Measures
Prophylactic antibiotic received within 1
hour prior to surgical incision
Prophylactic antibiotic selection for
surgical patients
Prophylactic antibiotics discontinued
within 24 hours after surgery end time
Cardiac Surgery patients with controlled
6 a.m. postoperative blood glucose
Patients with appropriate hair removal
Urinary catheter removed on
postoperative day 1 or 2
Patients with perioperative temperature
management
Patients on beta-blocker (BB) therapy
prior to arrival who received BB during
the perioperative period
Patients with recommended venous
thromboembolism (VTE) prophylaxis
ordered
Patients who received appropriate VTE
prophylaxis within 24 hours prior to
surgery and 24 hours after surgery
Greenville
Greer
Hillcrest
Patewood
CMS Hospital
Quality Alliance
Oct 12 - Dec 12
Oct 12 - Dec 12
Oct 12 - Dec 12
Oct 12 - Dec 12
Oct 11 - Sept 12
Num/
Den
Percent
Num/
Den
Percent
135/135 100.0%
110/110 100.0%
43/43
100.0%
135/135 100.0%
110/110 100.0%
43/43
130/132
98.5%
106/107 99.1%
74/74
100.0%
Percent
Num/
Den
N/A
N/A
Num/
Den
SC
Average
National
Average
Top
Performers
183/183 100.0%
99%
98%
100%
100.0%
183/183 100.0%
99%
99%
100%
40/40
100.0%
182/183 99.5%
98%
97%
100%
N/A
N/A
98%
96%
100%
N/A
Percent
N/A
212/212 100.0%
144/144 100.0%
59/60
98.3%
222/222 100.0%
NA
NA
NA
101/116
87.1%
120/122 98.4%
54/55
98.2%
196/197 99.5%
97%
96%
100%
135/135 100.0%
144/144 100.0%
60/60
100.0%
222/222 100.0%
100%
100%
100%
93.1%
14/15
93.3%
96.2%
96%
97%
100%
75/79
94.9%
27/29
92/93
98.9%
126/126 100.0%
59/60
98.3%
200/200 100.0%
99%
98%
100%
90/93
96.8%
126/126 100.0%
59/60
98.3%
200/200 100.0%
98%
98%
100%
Performing at or above Organizational target of 98%.
50/52
Performing below Organizational target of 98%.
• Report generated April 2013 All Care Measures – GHS Outpatient
Annual Composite Score: 98.9%
All Care Measure Score: 98.1%
OUTPATIENT MEASURES
Jan 12
Feb 12
Mar 12
Apr 12
May 12
Jun 12
Jul 12
Aug 12
Sep 12
Oct 12
Nov 12
Dec 12
Rolling 12
Months:
Jan 12Dec 12
Greenville Memorial 100.0%
93.7%
97.1%
100.0%
97.0%
100.0%
98.6%
95.7%
96.7%
98.6%
98.6%
96.9%
97.8%
Greer Memorial
100.0%
100.0%
94.7%
100.0%
90.9%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
98.5%
Hillcrest Memorial
100.0%
100.0%
100.0%
83.3%
91.7%
100.0%
100.0%
91.7%
100.0%
100.0%
100.0%
100.0%
97.6%
Patewood
Memorial OP Surg
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
GHS
100.0%
95.5%
97.1%
98.8%
95.8%
100.0%
99.0%
95.9%
97.8%
99.1%
99.0%
98.2%
98.1%
Facility
Performing at or above FY11 Organizational target of 93.0%
• Report generated April 2013 Outpatient ED and Surgical Measures
Quarterly Composite Score: 98.9%
All Care Measure Score: 98.1%
Greenville
Greer
Hillcrest
CMS Hospital
Quality Alliance
Oct 11 - Sept 12
Patewood
Oct 12 - Dec 12
Oct 12 - Dec 12
Oct 12 - Dec 12
Oct 12 - Dec 12
Num/
Den
Percent
Num/
Den
Percent
Num/
Den
Percent
Num/
Den
Percent
SC
Average
National
Average
Top
Performers
Median time to transfer to another facility
for acute coronary intervention
0 patients
N/A
3
patients
33mins
5
patients
21 mins
0 patients
N/A
50 mins
58 mins
38 mins
Aspirin at arrival
0 patients
N/A
7/7
100.0%
12/12
100.0%
0 patients
N/A
98%
97%
100%
Median time to
electrocardiogram (ECG)
0 patients
N/A
6
patients
2.5
mins
11
patients
0 mins
0 patients
N/A
6 mins
7 mins
3 mins
Aspirin at Arrival
0 patients
N/A
16/16
100.0%
16/16
100.0%
0 patients
N/A
98%
97%
100%
Median Time to ECG
0 patients
N/A
16
patients
1
mins
16
patients
0.5
mins
0 patients
N/A
6 mins
7 mins
3 mins
Median time from ED arrival to ED
departure for discharged ED patients
Median time from ED arrival to diagnostic
evaluation by a Qualified Medical
Personnel
OP Pain Management
95
patients
212
mins
100
patients
147
mins
100
patients
131.5
mins
0 patients
N/A
135 mins
138 mins
91 mins
86
patients
76.5
mins
96
patients
55.5
mins
89
patients
81
mins
0 patients
N/A
32 mins
28 mins
14 mins
Median time to pain management for long
bone fracture
OP Stroke
96
patients
34.5
mins
45
patients
56
mins
26
patients
74.5
mins
0
patients
N/A
60 mins
60 mins
37 mins
1/3
33.3%
1/1
100.0%
3/3
100.0%
0
patients
N/A
52%
46%
100%
202/203
99.5%
17/17
100.0%
1/1
100.0%
49/49
100.0%
98%
97%
100%
201/202
99.5%
17/17
100.0%
1/1
100.0%
49/49
100.0%
98%
97%
100%
Outpatient AMI
Outpatient Chest Pain
OP ED-Throughput
Head CT/MRI results for acute stroke
patients who received scan interpretation
w/in 45 min. of arrival
Outpatient Surgery
Prophylactic antibiotic within 1 hour prior
to surgical incision
Prophylactic antibiotic selection for
surgical patients
Performing at or above Organizational target of 98%.
Performing below Organizational target of 98%.
• Report generated April 2013 Value Based Purchasing
Clinical Core Measures
Greenville Health System – Year 2 (FY 2014)
Quality Measure Performance Report
Value Based Purchasing Clinical Measures
CFG/Population - Measure
GREENVILLE HOSPITAL
SYSTEM
Apr - Dec 12
Num
Den
Rate
VBP
Achievement
Score
VBP
Improvement
Score
Threshold
Score
CMS
Benchmark
Score
0 - 10
0-9
Rate
Rate
IP AMI
IP AMI
Fibrinolytic Therapy Received Within 30 Minutes
Primary PCI Received Within 90 Minutes
0
114
0
114
NA
100.00%
IP AMI
NA
NA
10
9
IP HF
80.66%
93.44%
IP HF
Discharge Instructions
454
458
99.13%
8
IP HF
8
92.66%
IP PN
IP PN
Blood Cultures Performed Prior to Initial Abx in ED
Antibiotic Selection
479
261
488
264
98.16%
98.86%
3
100.00%
IP PN
0
8
IP SCIP
96.30%
100.00%
5
IP SCIP
97.30%
94.46%
100.00%
100.00%
IP SCIP
1337
1337
1296
239
1293
522
1337
1338
1311
240
1356
545
100.00%
99.93%
98.86%
99.58%
95.35%
95.78%
10
9
7
9
4
1
9
8
3
0
2
0
98.07%
98.13%
96.63%
96.34%
92.86%
95.65%
100.00%
100.00%
99.96%
99.63%
99.89%
100.00%
Recommended Venous Thromboembolism Prophylaxis
Ordered
Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24
hrs after Surg
1302
1308
99.54%
9
7
94.62%
100.00%
1297
1308
99.16%
8
8
94.92%
99.83%
GHS Facility Aggregate
9931
10067
98.65%
86 out of possible 120 points
59 improvement points
Prophylactic Antibiotic Timing
Prophylactic Antibiotic Regimen
Prophylactic Antibiotic discontinued within 24 hrs post op
Blood Sugar Controlled in Cardiac Surgery Patients
Urinary Catheter Removed Post op Day 1 or 2
Received BB During Perioperative Period
Greenville Hospital System Core Measure Domain
Score
≥ Target Score of 98%
71.67%
< Target Score of 98%
Threshold = Median score among all hospitals during baseline period
Benchmark = Mean of the top decile
• Report generated April 2013 Value Based Purchasing
Clinical Core Measures
Greenville Memorial – Year 2
GREENVILLE
Apr - Dec 12
Quality Measure Performance Report
Value Based Purchasing Clinical Measures
CFG/Population - Measure
Num
Den
Rate
VBP
Achievement
Score
VBP
Improvement
Score
Threshold
Score
CMS
Benchmark
Score
0 - 10
0-9
Rate
Rate
IP AMI
IP AMI
Fibrinolytic Therapy Received Within 30 Minutes
Primary PCI Received Within 90 Minutes
0
0
NA
NA
114
114
100.00%
10
IP HF
IP AMI
NA
80.66%
9
93.44%
IP HF
Discharge Instructions
377
380
99.21%
9
Blood Cultures Performed Prior to Initial Abx in ED
Antibiotic Selection
326
149
334
151
97.60%
98.68%
8
2
7
IP SCIP
92.66%
429
100.00%
429
430
99.77%
Prophylactic Antibiotic discontinued within 24 hrs post op
410
415
Blood Sugar Controlled in Cardiac Surgery Patients
Urinary Catheter Removed Post op Day 1 or 2
239
280
Received BB During Perioperative Period
Prophylactic Antibiotic Regimen
Recommended Venous Thromboembolism Prophylaxis
Ordered
Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to
thru 24 hrs after Surg
GMH VBP Composite Score
429
0
6
97.30%
94.46%
100%
100.00%
IP SCIP
9
98.07%
100.00%
8
7
98.13%
100%
98.80%
6
6
96.63%
100%
240
332
99.58%
9
0
96.34%
99.63%
84.34%
0
1
92.86%
99.89%
233
245
95.10%
0
1
95.65%
100.00%
272
273
99.63%
9
7
94.62%
100.00%
267
273
97.80%
94.92%
99.83%
3525 3616 97.48%
10
6
6
78 out of
60
possible improvement
120 points
points
65.00%
Greenville Memorial Core Measure Domain Score
≥ Target Score of 98%
100%
IP PN
IP SCIP
Prophylactic Antibiotic Timing
100%
IP HF
IP PN
IP PN
96.30%
< Target Score of 98%
Threshold = Median score among all hospitals during baseline period
Benchmark = Mean of the top decile
• Report generated April 2013 Value Based Purchasing
Clinical Core Measures
Greer Memorial – Year 2
GREER
Apr - Dec 12
Quality Measure Performance Report
Value Based Purchasing Clinical Measures
CFG/Population - Measure
Num
Den
Rate
VBP
Achievement
Score
VBP
Improvement
Score
Threshold
Score
CMS
Benchmark
Score
0 - 10
0-9
Rate
Rate
IP AMI
IP AMI
IP AMI
Fibrinolytic Therapy Received Within 30 Minutes
0
0
NA
NA
NA
Primary PCI Received Within 90 Minutes
0
0
NA
NA
NA
80.66%
93.44%
IP HF
IP HF
Discharge Instructions
49
49
100.00%
10
IP PN
IP HF
9
92.66%
IP PN
Blood Cultures Performed Prior to Initial Abx in ED
Antibiotic Selection
93
57
93
57
100.00%
100.00%
10
10
100.00%
IP PN
0
0
97.30%
94.46%
IP SCIP
IP SCIP
96.30%
100%
100.00%
100.00%
IP SCIP
Received BB During Perioperative Period
323
323
318
349
90
323 100.00%
323 100.00%
321 99.07%
356 98.03%
94.74%
95
10
10
7
7
0
9
9
0
4
0
98.07%
98.13%
96.63%
92.86%
95.65%
100.00%
100.00%
99.96%
99.89%
100.00%
Recommended Venous Thromboembolism Prophylaxis
Ordered
359
361
99.45%
9
0
94.62%
100.00%
Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru
24 hrs after Surg
359
361
99.45%
9
4
94.92%
99.83%
82 out of
possible
100 points
35
improvement
points
Prophylactic Antibiotic Timing
Prophylactic Antibiotic Regimen
Prophylactic Antibiotic discontinued within 24 hrs post op
Urinary Catheter Removed Post op Day 1 or 2
GrMH VBP Composite Score
2320 2339 99.19%
82.00%
Greer Memorial Core Measure Domain Score
≥ Target Score of 98%
< Target Score of 98%
Threshold = Median score among all hospitals during baseline period
Benchmark = Mean of the top decile
• Report generated April 2013 Value Based Purchasing
Clinical Core Measures
Hillcrest Memorial – Year 2
HILLCREST
Apr - Dec 12
Quality Measure Performance Report
Value Based Purchasing Clinical Measures
CFG/Population - Measure
Num
Den
Rate
VBP
VBP
Achievement Improvement
Score
Score
0 - 10
IP AMI
Threshold
Score
CMS
Benchmark
Score
Rate
Rate
0-9
IP AMI
IP AMI
Fibrinolytic Therapy Received Within 30 Minutes
0
0
NA
NA
NA
80.66%
96.30%
Primary PCI Received Within 90 Minutes
0
0
NA
NA
NA
93.44%
100%
IP HF
IP HF
Discharge Instructions
28
29
96.55%
5
IP HF
6
92.66%
IP PN
IP PN
100.00%
IP PN
Blood Cultures Performed Prior to Initial Abx in ED
60
61
98.36%
4
4
97.30%
100.00%
Antibiotic Selection
55
56
98.21%
7
0
94.46%
100.00%
IP SCIP
IP SCIP
IP SCIP
Prophylactic Antibiotic Timing
112
112 100.00%
10
0
98.07%
100.00%
Prophylactic Antibiotic Regimen
112
112 100.00%
10
0
98.13%
100.00%
Prophylactic Antibiotic discontinued within 24 hrs post op
104
108
96.30%
0
0
96.63%
99.96%
Urinary Catheter Removed Post op Day 1 or 2
154
156
98.72%
8
7
92.86%
99.89%
44
45
97.78%
5
0
95.65%
100.00%
164
167
98.20%
6
7
94.62%
100.00%
164
167
98.20%
7
8
94.92%
99.83%
Received BB During Perioperative Period
Recommended Venous Thromboembolism Prophylaxis
Ordered
Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru
24 hrs after Surg
HMH VBP Composite Score
997 1013 98.42%
Hillcrest Memorial Core Measure Domain Score
≥ Target Score of 98%
65 of
32
possible improvement
100 points
points
65.00%
< Target Score of 98%
Threshold = Median score among all hospitals during baseline period
Benchmark = Mean of the top decile
• Report generated April 2013 Value Based Purchasing
Clinical Core Measures
Patewood Memorial – Year 2
PATEWOOD
Apr - Dec 12
Quality Measure Performance Report
Value Based Purchasing Clinical Measures
CFG/Population - Measure
Num
Den
Rate
VBP
Achievement
Score
VBP
Improvement
Score
Threshold
Score
CMS
Benchmark
Score
0 - 10
0-9
Rate
Rate
IP SCIP
IP SCIP
IP SCIP
Prophylactic Antibiotic Timing
473
473 100.00%
10
0
98.07%
100.00%
Prophylactic Antibiotic Regimen
473
473 100.00%
10
9
98.13%
100.00%
Prophylactic Antibiotic discontinued within 24 hrs post op
464
467
99.36%
8
2
96.63%
99.96%
Urinary Catheter Removed Post op Day 1 or 2
510
512
99.61%
9
3
92.86%
99.89%
Received BB During Perioperative Period
155
160
96.88%
3
0
95.65%
100.00%
Recommended Venous Thromboembolism Prophylaxis
Ordered
507
507
100.00%
10
0
94.62%
100.00%
Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru
24 hrs after Surg
507
507
100.00%
10
0
94.92%
99.83%
PMH VBP Composite Score
60 of
14
3089 3099 99.68% possible 70 improvement
points
points
85.71%
Patewood Memorial Core Measure Domain Score
≥ Target Score of 98%
< Target Score of 98%
Threshold = Median score among all hospitals during baseline period
Benchmark = Mean of the top decile
• Report generated April 2013 Core Measures
•  Opportunities (5 or More Defects)
–  Urinary Catheter Removed on Post Op Day 1 or 2 – GMH (15);
Greer (2): HMH (1); PMH (1)
–  Continuation of Beta Blockers Perioperatively – GMH (4); Greer
(2), HMH (1); PMH (2)
•  Accomplishments and Improvements
–  Top Quartile Performance in Core Measures
–  Greenville MSA Rated #2 in Nation on CMS Value Based
Purchasing Program in Year 1
–  Ongoing Quality Teams for AMI, CHF, PN, SCIP
–  Lean Six Sigma Project on CAUTI Reduction (Foley Catheter)
–  CPOE Alert to Remind Physicians About Day 1 and 2 for Beta
Blockers
Mortality
Premier Database Jan 2012 – Dec 2012
Greenville
Greer Hillcrest
Patewood
GHS
Baptist Easley Mortality Mortality Mortality Total Mortality Rate -­‐ Index Index Number of Rate Prior Current Current Prior 12 Deaths prior 12 Months Quarter Quarter Months 12 Months 2.24%
0.91
2.44%
0.90
881
0.85%
0.51
0.79%
0.54
31
0.65%
0.32
0.72%
0.39
12
0.00%
0.00
0.00%
0.00
0
1.99%
0.86
2.16%
0.87
924
2.38%
0.99
1.96%
0.70
Crimson Data Base (Apr 2012 – Mar 2013)
GHS Mortality Rate = 2.02%; Mortality Index = 0.80
GMH Mortality Rate = 2.26%; Mortality Index = 0.87
89
Mortality
•  AHRQ Inpatient Quality Indicators (IQI)
–  Statistically different than expected at Greenville Memorial:
–  Craniotomy; PTCA; Hip Fracture; GI Bleed
•  UHC Data Base (Jan 2012 – Dec 2012) GMH Only
Measure Adj.Ra-o UHC Median UHC Rank AHRQ IQI 90 Surgical Composite 1.27 1.01 111/119 AHRQ IQI 91 Medical Composite 0.80 0.82 52/119 •  Improvements
–  Sepsis Team In Place with Some Initial Improvements
–  Huron Group Working on Coding and Documentation
–  Clemson Team Looking at Mortality Data
Mortality Rate
System-wide Trending
Mortality Rate
Facility
CY 2011
Q1 2012
Q2 2012
Q3 2012
Q4 2012
CY 2012
Mortality Mortality Rate Rate Index
Mortality Mortality Rate Rate Index
Mortality Mortality Rate
Rate Index
Mortality Mortality Rate Rate Index
Mortality Mortality Rate Rate Index
Mortality Mortality Rate
Rate Index
Greenville Hospital System
2.17%
0.83
2.40%
0.92
2.17%
0.86
2.08%
0.82
1.99%
0.86
2.16%
0.87
Greenville Memorial
2.49%
0.88
2.68%
0.95
2.48%
0.89
2.36%
0.85
2.24%
0.91
2.44%
0.90
Greer Memorial
0.63%
0.41
0.87%
0.59
0.60%
0.56
0.78%
0.50
0.85%
0.51
0.79%
0.54
Hillcrest Memorial
0.39%
0.18
1.43%
0.57
0.29%
0.22
0.45%
0.33
0.65%
0.32
0.72%
0.39
Patewood Memorial
0.10%
1.53
0.00%
0.00
0.00%
0.00
0.00%
0.00
0.00%
0.00
0.00%
0.00
Observed rate is significantly ≤ than Expected (O/E ratio ≤ 1.0 and statistically significant)
The ratio of Observed to Expected Mortality is ≤ 1 but not statistically significant (O/E ratio ≤ 1.0)
The ratio of Observed to Expected Mortality is > 1 but not statistically significant (O/E ratio > 1.0)
Observed rate is significantly > than Expected (O/E ratio > 1.0 and statistically significant)
• Report generated April 2013 Mortality Rate by DRG Business Line
Greenville Hospital System
`
2012 Greenville Hospital System -­‐ Mortality Rate
DRG Business Line
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
29
16
17
19
22
23
24
28
25
26
CARDIAC SURGERY
CARDIOLOGY
ENT
GENERAL SURGERY
GYNECOLOGY
HEMATOLOGY/ONCOLOGY
INTERNAL MEDICINE
MEDICAL ONCOLOGY
NEONATOLOGY
NEUROLOGY
NEUROSURGERY
OBSTETRICS
OPHTHALMALOGY
ORGAN TRANSPLANT
ORTHOPEDICS
ORTHOPEDICS -­‐ SPINAL
PEDIATRIC MEDICINE
PEDIATRIC SURGERY
PSYCHIATRY
SURGICAL ONCOLOGY
THORACIC SURGERY
TRAUMA
TRAUMA -­‐ OTHER
UROLOGY
VASCULAR SURGERY
2012 Q1 2012 Q2 2012 Q3 2012 Q4 Mortality Mortality Mortality Mortality Outcome
Rate I ndex Rate I ndex Rate I ndex Rate I ndex
Cases
1.17
1.35
0.00
0.56
0.00
1.03
0.96
0.82
0.67
1.01
1.50
0.00
0.00
0.92
1.02
0.00
0.64
0.00
0.94
0.99
0.60
0.88
0.88
0.95
0.00
0.00
1.07
1.77
0.00
0.00
0.00
1.25
0.99
0.74
0.00
2.16
0.66
0.72
8.59
0.00
2.87
0.00
0.00
1.10
0.78
0.00
0.00
0.00
0.97
0.83
0.00
0.64
0.00
0.77
0.77
0.58
1.28
0.94
1.31
0.00
0.00
0.00
0.85
0.00
0.54
0.00
2.60
2.29
0.34
1.33
1.19
0.00
1.40
0.87
0.80
8.52
0.95
0.00
0.22
0.95
0.38
1.03
0.72
1.01
0.00
0.00
0.00
2.06
4.66
0.00
2.49
1.70
0.00
0.00
1.18
0.00
4.78
0.00
481
445
70
828
14
258
2,307
92
1,337
421
107
1,420
8
6
334
110
412
60
150
72
117
203
40
128
113
Current Quarter -­‐ 2012 Q4
Observed Expected Mortality Mortality Mortality Deaths
Rate
Rate
Rate I ndex Comments
13
10
2
19
0
1
112
4
8
14
5
0
0
0
6
1
0
2
1
0
0
14
0
2
0
2.70%
2.25%
2.86%
2.29%
0.00%
0.39%
4.85%
4.35%
0.60%
3.33%
4.67%
0.00%
0.00%
0.00%
1.80%
0.91%
0.00%
3.33%
0.67%
0.00%
0.00%
6.90%
0.00%
1.56%
0.00%
3.10%
2.80%
0.34%
2.43%
0.12%
1.74%
5.09%
11.45%
0.58%
4.62%
4.61%
0.01%
0.02%
0.04%
0.87%
0.19%
0.17%
1.34%
0.39%
0.64%
3.30%
5.85%
1.73%
0.33%
0.92%
0.87
0.80
8.52
0.95
0.00
0.22
0.95
0.38
1.03
0.72
1.01
0.00
0.00
0.00
2.06
4.66
0.00
2.49
1.70
0.00
0.00
1.18
0.00
4.78
0.00
Observed rate is significantly ≤ than Expected (O/E ratio ≤ 1.0 and statistically significant)
The ratio of Observed to Expected Mortality is ≤ 1 but not statistically significant (O/E ratio ≤ 1.0)
The ratio of Observed to Expected Mortality is > 1 but not statistically significant (O/E ratio > 1.0)
Observed rate is significantly > than Expected (O/E ratio > 1.0 and statistically significant)
• Report generated April 2013 AHRQ Inpatient Quality Indicators
Jan 12 – Dec 12
Data source: UHC & Premier
Greenville Memorial's Performance on AHRQ Quality Measures Greenville Memorial
Premier
UHC
Inpatient Quality Indicators (Rate %)
IQI 8 Esophageal Resection Mortality Rate
IQI 9 Pancreatic Resection Mortality Rate
IQI 11 AAA Repair Mortality Rate
IQI 12 CABG Mortality Rate
IQI 13 Craniotomy Mortality Rate◂
IQI 14 Hip Replacement Mortality Rate
IQI 15 AMI Mortality Rate
IQI 16 Congestive Heart Failure (CHF) Mortality Rate
IQI 17 Acute Stroke Mortality Rate
IQI 18 Gastrointestinal (GI) Hemorrhage Mortality Rate◂
IQI 19 Hip Fracture Mortality Rate◂
IQI 20 Pneumonia Mortality Rate
IQI 30 PTCA Mortality Rate◂
IQI 31 CEA Mortality Rate
IQI 32 AMI Mortality Rate, without Transfer Cases
Outcomes / Discharges
1/12
0/10
1/57
10/361
20/191 *
0/3
52/832
25/705
84/798
17/484 *
11/218 *
28/633
39/1091 *
0/136
28/492
Rate (%)
Premier Peer Outcomes / Rate
Discharges
8.33%
0.00%
1.75%
2.77%
10.47%
0.00%
6.25%
3.55%
10.53%
3.51%
3.45%
6.06%
3.51%
2.39%
5.30%
0.03%
4.73%
3.22%
9.26%
1.97%
5.05%
4.42%
3.57%
0.00%
5.69%
2.20%
3.34%
1.76%
0.67%
4.71%
1/12
0/12
1/63
10/361
20/195 *
0/3
53/834
25/718
87/806
17/489
11/219 *
28/650
39/1093 *
0/139
29/494
Jan '12 -­‐ Dec '12 (Rolling 1 2 months)
Rate (%)
UHC Peer Rate
8.33%
0.00%
1.59%
2.77%
10.26%
0.00%
6.35%
3.48%
10.79%
3.48%
2.80%
1.69%
3.65%
2.79%
4.88%
0.05%
5.41%
2.94%
10.43%
2.29%
5.02%
4.31%
3.57%
0.00%
5.87%
2.71%
3.19%
2.37%
0.49%
5.12%
Facility rate > Peer group benchmark rate
*
Indicates that the rate i s s tatistically significantly different than the peer
• Report generated April 2013 AHRQ Inpatient Quality Indicators
Jan 12 – Dec 12
Data source: Premier
Greer, Hillcrest & Patewood Performance on AHRQ Quality Measures
Greer
Inpatient Quality Indicators (Rate %)
IQI 8 Esophageal Resection Mortality Rate
IQI 9 Pancreatic Resection Mortality Rate
IQI 11 AAA Repair Mortality Rate
IQI 12 CABG Mortality Rate
IQI 13 Craniotomy Mortality Rate
IQI 14 Hip Replacement Mortality Rate
IQI 15 AMI Mortality Rate
IQI 16 Congestive Heart Failure (CHF) Mortality Rate
IQI 17 Acute Stroke Mortality Rate
IQI 18 Gastrointestinal (GI) Hemorrhage Mortality Rate
IQI 19 Hip Fracture Mortality Rate
IQI 20 Pneumonia Mortality Rate
IQI 30 PTCA Mortality Rate
IQI 31 CEA Mortality Rate
IQI 32 AMI Mortality Rate, without Transfer Cases
Outcomes / Discharges
Hillcrest
Rate (%)
Outcomes / Discharges
Rate (%)
Patewood
Outcomes / Discharges
0/0
0/0
0/0
0/0
0/0
0/0
0/0
0/0
0/0
0/0
0/0
0/0
0/0
0/0
0/0
0/164
0/3
3/92
1/12
0/90
0/59
4/175
0.00%
0.00%
3.26%
8.33%
0.00%
0.00%
2.29%
0/46
0/1
1/49
0/5
2/27
0/36
1/133
0.00%
0.00%
2.04%
0.00%
7.41%
0.00%
0.75%
0/230
0/0
0/0
0/0
0/2
0/0
0/0
0/0
0/0
0/0
0/0
0.00%
Jan '12 -­‐ Dec '12 (Rolling 1 2 months)
0/1
0.00%
0.00%
0/0
0/0
0/3
Rate (%)
0/0
0.00%
Premier Peer Group
4.35%
2.30%
4.80%
2.43%
6.00%
0.03%
4.73%
3.44%
9.39%
1.95%
2.09%
3.49%
2.04%
0.43%
4.68%
Facility rate > Peer group benchmark rate
*
Indicates that the rate i s s tatistically s ignificantly higher than the peer
• Report generated April 2013 Cancer 5-­‐Year Survival by Site: GHS vs. NCDB Teaching/ Research Hospitals
• Report generated October 2012 Premier 30 Day, Same
Hospital Readmissions Jan 2012 – Dec 2012
Readmission Readmission Readmission Readmission Rate -­‐ Current Index Current Rate Prior 12 Index Prior 12 Quarter Quarter Months Months GMH
Greer HMH PMH GHS 10.24%
5.45%
4.62%
0.30%
9.25%
0.98
0.63
0.40
0.07
0.91
9.92%
4.47%
5.06%
0.43%
8.96%
0.93
0.52
0.43
0.10
0.87
Baptist Easley 8.00%
0.70
8.90%
0.77
Crimson Data Base
30 Day Readmission Rates (Any Diagnosis)
GHS Readmission Rate = 10.2%; Readmission Index = 0.91
30 Day Readmission Rates (Same Diagnosis)
GHS Readmission Rate = 1.4%; Readmission Index = 0.79
Readmission Rate
System-wide Trending
Readmission Rate Within 30 days
Facility
CY2011
Q1 2012
Q2 2012
Q3 2012
Q4 2012
CY 2012
Readmit Readmit Rate
Rate Index
Readmit Readmit Rate
Rate Index
Readmit Readmit Rate
Rate Index
Readmit Readmit Rate
Rate Index
Readmit Readmit Rate
Rate Index
Readmit Readmit Rate
Rate Index
Greenville Hospital System
9.03%
0.85
9.13%
0.87
8.08%
0.79
9.24%
0.89
9.25%
0.91
8.96%
0.87
Greenville Memorial
9.93%
0.91
10.13%
0.94
9.03%
0.84
10.18%
0.96
10.24%
0.98
9.92%
0.93
Greer Memorial
4.79%
0.54
4.09%
0.46
2.65%
0.34
5.31%
0.62
5.45%
0.63
4.47%
0.52
Hillcrest
Memorial
5.68%
0.46
5.48%
0.43
5.57%
0.50
4.75%
0.40
4.62%
0.40
5.06%
0.43
Patewood Memorial
0.47%
0.10
0.76%
0.16
0.00%
0.00
0.69%
0.14
0.30%
0.07
0.43%
0.10
Observed rate is significantly ≤ than Expected (O/E ratio ≤ 1.0 and statistically significant)
The ratio of Observed to Expected Readmits is ≤ 1 but not statistically significant (O/E ratio ≤ 1.0)
The ratio of Observed to Expected Readmits is > 1 but not statistically significant (O/E ratio > 1.0)
Observed rate is significantly > than Expected (O/E ratio > 1.0 and statistically significant)
• Report generated April 2013 Readmission Rate by DRG Business Line
Greenville Hospital System
Greenville Hospital System -­‐ Readmit Rate
Current Quarter -­‐ Q4 2012
DRG Business Line
1 CARDIAC SURGERY
2 CARDIOLOGY
3 ENT
4 GENERAL SURGERY
5 GYNECOLOGY
6 HEMATOLOGY/ONCOLOGY
7 INTERNAL MEDICINE
8 MEDICAL ONCOLOGY
9 NEONATOLOGY
10 NEUROLOGY
11 NEUROSURGERY
12 OBSTETRICS
13 OPHTHALMALOGY
14 ORGAN TRANSPLANT
15 ORTHOPEDICS
29 ORTHOPEDICS -­‐ SPINAL
16 PEDIATRIC MEDICINE
17 PEDIATRIC SURGERY
19 PSYCHIATRY
22 SURGICAL ONCOLOGY
23 THORACIC SURGERY
24 TRAUMA
28 TRAUMA -­‐ OTHER
25 UROLOGY
26 VASCULAR SURGERY
2012 2012
2012
2012 Q1 Q2 Q3 Q4 Readmit Readmit Readmit Readmit Rate I ndex Rate I ndex Rate I ndex Rate I ndex
0.73
0.86
1.54
0.89
0.54
1.01
0.86
0.94
1.34
0.80
0.86
1.18
2.01
0.00
0.95
1.24
1.29
1.27
1.00
1.27
1.22
0.36
0.68
1.15
1.32
0.65
0.74
0.25
0.94
1.09
1.02
0.80
1.07
1.77
0.59
0.86
0.93
0.00
0.00
0.97
0.59
0.83
1.12
0.86
1.00
0.40
0.57
1.10
0.65
0.79
0.71
0.82
0.54
1.07
0.62
1.15
0.95
0.91
1.44
0.71
0.94
1.16
0.00
0.00
0.73
0.46
1.48
0.83
0.79
1.04
0.47
0.80
0.19
1.00
0.72
0.87
0.85
0.90
0.94
1.90
1.06
0.96
0.84
1.37
0.99
0.64
1.09
1.84
0.00
1.35
1.55
1.09
0.98
0.38
1.53
0.85
0.85
1.27
0.81
1.11
Cases
483
446
72
832
14
259
2,316
92
1,352
422
108
1,420
8
6
336
110
417
60
150
72
117
205
40
128
113
Observed Expected Readmit Readmit Readmit Rate Readmit
Rate
Rate
Index
Comments
49
59
5
78
3
114
337
17
33
46
9
62
1
0
42
9
41
5
6
9
11
13
6
10
16
10.14%
13.23%
6.94%
9.38%
21.43%
44.02%
14.55%
18.48%
2.44%
10.90%
8.33%
4.37%
12.50%
0.00%
12.50%
8.18%
9.83%
8.33%
4.00%
12.50%
9.40%
6.34%
15.00%
7.81%
14.16%
11.69%
15.52%
7.74%
9.96%
11.29%
41.49%
15.15%
21.97%
1.79%
11.01%
13.04%
3.99%
6.78%
29.74%
9.25%
5.29%
9.00%
8.46%
10.42%
8.19%
11.12%
7.46%
11.81%
9.69%
12.70%
0.87
0.85
0.90
0.94
1.90
1.06
0.96
0.84
1.37
0.99
0.64
1.09
1.84
0.00
1.35
1.55
1.09
0.98
0.38
1.53
0.85
0.85
1.27
0.81
1.11
Observed rate is significantly ≤ than Expected (O/E ratio ≤ 1.0 and statistically significant)
The ratio of Observed to Expected Readmits is ≤ 1 but not statistically significant (O/E ratio ≤ 1.0)
The ratio of Observed to Expected Readmits is > 1 but not statistically significant (O/E ratio > 1.0)
Observed rate is significantly > than Expected (O/E ratio > 1.0 and statistically significant)
• Report generated April 2013 30-­‐Day All-­‐Cause Risk-­‐Standardized Readmission Results FY 2013 Hospital Readmissions Reduc-on Program
Based on Discharges from July 2008 through June 2011 (CMS) AMI
HF
PN
GMH
GrMH
HH
GMH
GrMH
HH
GMH
GrMH
HH
Readmissions
Eligible Discharges
Predicted Readmission Rate
Expected Readmission Rate
Na-onal Crude Readmission Rate
Excess Readmission Ra-o
83
2
0
181
14
14
110
33
20
654
23
2
1024
109
66
676
190
152
14.0%
20.7%
19.2%
19.0%
19.2%
23.1%
17.1%
17.5%
16.1%
17.4%
22.1%
19.4%
23.8%
21.7%
23.6%
18.8%
17.6%
17.6%
19.2%
19.2%
19.2%
24.6%
24.6%
24.6%
18.5%
18.5%
18.5%
0.8049
0.9361
0.9907
0.7959
0.8849
0.979
0.9049
0.9941
0.917
The 30-­‐day readmission rate predicted on the basis of your hospital’s performance with its observed case mix and your hospital’s es]mated effect on readmissions (provided in your hospital discharge level data)
The 30-­‐day readmission rate expected on the basis of average hospital performance with your
hospital’s case mix and the average hospital effect (provided in your hospital discharge-­‐level data).
The Excess Readmission Ra]o is the measure that will be used to determine the payment adjustment for the Program. If a hospital performs beaer than an average hospital that admiaed similar pa]ents (that is, pa]ents with similar risk factors for readmission such as age and comorbidi]es), the ra]o will be less than 1.0. If a hospital performs
worse than average, the ra]o will be greater than 1.0.
• Report generated July 2012 Patient Safety
•  National Patient Safety Goals
•  AHRQ Patient Safety Culture Survey
•  Harm Rates
–  Patient Safety Indicators
–  Global Trigger Tools (GTT) – Under Revision
–  Serious Safety Event Rate (SSER) – Under Development
•  Safety Events
•  Occurrence Reports
•  Adverse Events
•  CMS Partnership for Patients Initiative
– 
– 
– 
– 
Healthcare Acquired Conditions (HACs)
Patient Falls
Pressure Ulcers
Surgical Safety Checklist
•  SC Safe Care Initiative (High Reliability)
–  HRST
National Patient Safety Goals
Greenville Health System
Na-onal Pa]ent Pa-ent Safety Goals Suicide Safety ID Time Out Cri]cal Results Suicide Risk Assessment, 94.1% Med Reconcilia]on 96.1% 95.4% 91.1% Pa-ent ID, 84.5% 90.7% 85.3% 83.3% 79.7% 78.6% 83.1% 79.5% Combined Results, 76.7% 75.2% Cri-cal Results, 74.3% 70.3% Q2 2011 Q4 90.5% 88.5% 84.1% 81.3% 78.6% 69.6% Combined = 88.5%
61.9% Q3 91.2% 69.1% 67.0% Med Reconcilia-on, 64.3% Q1 98.7% 75.0% 72.0% 71.5% 72.0% 92.4% 91.6% 90.5% 88.6% 83.4% 82.9% 81.9% 80.1% 78.9% 77.2% 75.0% 72.7% 99.3% 98.2% 93.9% Time Out, 89.4% Combined Results Q1 Q2 Q3 Q4 2012 Action Steps
WorkOut Completed and Action Plan Implemented for Critical Test Results
Evaluating Suicide Risk Process in Emergency Department
• Report generated April 2013 National Patient Safety Goal
03.05.01 – Inpatient Anticoagulation Therapy, Warfarin
reported in rolling 12-month increments
Data sources: Sunquest Laboratory and Siemens Pharmacy data systems
% INRs within "Therapeu-c" Range ( 2.0 -­‐ 3.5 seconds ) 40% Trended graphs are for the acute care
population at Greenville Memorial only
Ini-a-ves started on January 1, 2009 COUNT of INR Results 35% 35.80% 35.77% 2.0 -­‐ 3.5 34.15% 30% * Baseline data *JAN 08 -­‐ 32.30% 30.72% 29.72% 25% *JAN 08 -­‐ JAN 09 -­‐ APR 09 -­‐ JUL 09 -­‐ OCT 09 -­‐ JAN 10 -­‐ APR 10 -­‐ JUL 10 -­‐ OCT 10 -­‐ JAN 11 -­‐ APR 11 -­‐ JUL 11 -­‐ OCT 11 -­‐ JAN 12 -­‐ APR 12 -­‐ DEC 08 DEC 09 MAR 10 JUN 10 SEP 10 DEC 10 MAR 11 JUN 11 SEP 11 DEC 11 MAR 12 JUN 12 SEP 12 DEC 12 MAR 13 % INRs in "Cri-cal Value" Range ( ≥ 5.0 seconds ) 3.5% Ini-a-ves started on January 1, 2009 3.0% 2.5% 2.63% 2.0% 1.5% 1.0% 0.5% 0.0% 1.91% 1.90% 1.56% 2.00% 1.62% Lower numbers reflect beaer performance for this metric. *JAN 08 -­‐ JAN 09 -­‐ APR 09 -­‐ JUL 09 -­‐ OCT 09 -­‐ JAN 10 -­‐ APR 10 -­‐ JUL 10 -­‐ OCT 10 -­‐ JAN 11 -­‐ APR 11 -­‐ JUL 11 -­‐ OCT 11 -­‐ JAN 12 -­‐ APR 12 -­‐ DEC 08 DEC 09 MAR 10 JUN 10 SEP 10 DEC 10 MAR 11 JUN 11 SEP 11 DEC 11 MAR 12 JUN 12 SEP 12 DEC 12 MAR 13 Goal: reduce the likelihood of patient harm related to major bleeding.
5.0 + PERCENTAGES Denominator 2.0 -­‐ 3.5 5.0 + DEC 08 4,804 425 16,165 29.72% 2.63% JAN 09 -­‐ DEC 09 5,526 342 17,989 30.72% 1.90% APR 09 -­‐ MAR 10 5,454 327 17,692 30.83% 1.85% JUL 09 -­‐ JUN 10 5,335 282 17,262 30.91% 1.63% OCT 09 -­‐ SEP 10 5,257 279 17,072 30.79% 1.63% JAN 10 -­‐ DEC 10 5,643 272 17,469 32.30% 1.56% APR 10 -­‐ MAR 11 5,798 252 17,702 32.75% 1.42% JUL 10 -­‐ JUN 11 6,094 290 18,204 33.48% 1.59% OCT 10 -­‐ SEP 11 6,201 282 17,935 34.57% 1.57% JAN 11 -­‐ DEC 11 5,836 276 17,088 34.15% 1.62% APR 11 -­‐ MAR 12 5,756 274 16,338 35.23% 1.68% JUL 11 -­‐ JUN 12 5,482 263 15,508 35.35% 1.70% OCT 11 -­‐ SEP 12 5,416 289 15,211 35.61% 1.90% JAN 12 -­‐ DEC 12 5,110 272 14,275 35.80% 1.91% APR 12 -­‐ MAR 13 4,822 270 13,479 35.77% 2.00% • Report generated April 2013 AHRQ Patient Safety
Culture Survey Change from Nov. ‘08 to August ‘12
GHS
Baseline
December
2008
GHS
August
2010
GHS
August
2011
1. Teamwork within Units
77.5%
81.5%
82.7%
83.4%
2. Supervisor / Mgr Expectations & Actions Promote Pt
Safety
77.6%
77.0%
77.1%
79.2%
3. Management Support for Patient Safety
69.5%
72.1%
71.4%
72.3%
4. Organizational Learning - Continuous Improvement
71.7%
71.3%
68.4%
70.6%
5. Overall Perceptions of Patient Safety
62.3%
65.1%
66.2%
68.1%
6. Feedback & Communication about Error
60.9%
61.6%
64.5%
65.6%
7. Communication Openness
60.8%
60.6%
62.6%
65.0%
8. Frequency of Events Reported
62.4%
63.0%
63.3%
66.6%
9. Teamwork across Units
51.9%
56.0%
56.6%
57.0%
10. Staffing
54.8%
57.3%
56.1%
55.4%
11. Handoffs and Transitions
40.0%
41.4%
39.1%
38.9%
12. Non-Punitive Response to Error
32.4%
36.8%
41.4%
45.0%
OVERALL ROLLED-UP SCORE
59.8%
62.4%
62.8%
64.2%
Composite
Green – Statistically significant increase since Baseline
Yellow - Not significantly different from Baseline
Red - Statistically significant decrease since Baseline
Survey carried out in Aug-Sep, 2012
Survey response rate was 3100/ 10,934 = 28.4%
Comparisons: AHRQ 2011 Database
GHS
GHS
AHRQ
August Compared All Hospitals
2012
to Mean
- Mean
ö
ö
ð
ð
ð
ð
ö
ö
ð
ð
ò
ð
ð
ñ
ö
ð
ø
ò
AHRQ
All
Hospitals 75th % ile
80%
83%
75%
79%
72%
79%
72%
77%
66%
71%
64%
69%
62%
66%
63%
68%
58%
64%
57%
62%
45%
51%
44%
49%
63%
68%
> 5% better than AHRQ mean
2.5 - 4.9% better than AHRQ mean
0 - ± 2.4% difference from AHRQ mean
2.5 – 4.9% worse than AHRQ mean
> 5% worse than AHRQ mean
Safety Culture
•  Opportunities for Improvement
–  Punitive Culture
–  Handoffs and Communication
•  Accomplishments and Improvements
–  Implementation of Just Culture …
•  Trained entire leadership team
•  39% improvement in punitive culture results to above national mean
•  Ongoing training and reinforcement
–  Handoffs and Communications
•  Lean Six Sigma Project Beginning For ED to Medical Surgical Floor Transition
•  OB Team Rounding Project
•  ACGME Academic Council Clinical Learning Environment
–  Project Plans in Place to Increase Survey Participation Rate
•  Specific Surveys for Ambulatory Practices, Nursing Home and Pharmacy
–  SC Safe Care Initiative – High Reliability
AHRQ Patient Safety
Indicators Jan 2012 – Dec 2012
•  Premier Data Base - Statistically Better than Expected
–  Accidental Puncture and Laceration (GMH)* (top quartile)
–  Birth Trauma Injury to Neonate (GMH)* (top decile)
•  Premier Data Base - Statistically Worse than Expected
–  Post Op Respiratory Failure, Post Op Sepsis, OB Trauma with
Instrument (GMH)
•  UHC Composites (GMH)
Measure AHRQ PDI 99 Pediatric Composite •  * PLean
Sigma
Projects
AHRQ SI 90 MSix
edical Composite Adj.Ra-o UHC Median UHC Rank 1.27 0.92 3/118 0.83 20/119 in OB
0.61 AHRQ Patient Safety Indicators
Jan 12 – Dec 12
Data source: UHC & Premier
Greenville Memorial's Performance on AHRQ Safety Measures
Greenville Memorial
Premier
UHC
Patient Safety Indicators (Rate per 1 000)
PSI 02 -­‐ Death i n Low Mortality DRGs
PSI 03 -­‐ Decubitus Ulcer
PSI 04 -­‐ Death i n Surgical Pts w Treatable Complications
PSI 05 -­‐ Foreign Body Left During Procedure ( Count)
PSI 06 -­‐-­‐ Iatrogenic Pneumothorax
PSI 07 -­‐ Central Line Associated Bloodstream Infection
PSI 08 -­‐-­‐ Postoperative Hip Fx
PSI 09 -­‐ Postop Hemorrhage or Hematoma◂
PSI 10 -­‐ Postop Physiological & Metabolic Derangement
PSI 11 -­‐ Postop Respiratory Failure◂
PSI 12 -­‐-­‐ Postoperative PE or DVT◂
PSI 13 -­‐-­‐ Postoperative Sepsis◂
PSI 14 -­‐ Postop Wound Dehiscence
PSI 15 -­‐ Accidental Puncture or Laceration◂
PSI 17 -­‐ Birth Trauma Injury to Neonate◂
PSI 18 -­‐ OB Trauma V aginal Delivery with Instrument ◂
PSI 19 -­‐ OB Trauma V aginal Delivery without Instrument
Outcomes / Discharges
Risk-­‐
Adjusted Rate
Premier Peer Rate
0.32
0.77
129.77
0.15
0.73
127.70
0.55
0.54
0/5866
0.00
21/8227
2.55
1/2315
0.43
27.12
46/1696 *
50/8218
6.08
19.30
11/570 *
2/1419
1.41
1.84
40/21757 *
1.32
6/4539 *
221.48
33/149 *
73/2915
25.04
0.48
0.58
0.07
2.81
0.95
13.39
6.48
9.75
1.33
2.70
2.98
139.63
20.80
2/6333
5/6511
51/393
0
11/20056
10/18610
Jan '12 -­‐ Dec '12 (Rolling 1 2 months)
Outcomes / Discharges
Risk-­‐
Adjusted Rate
UHC Peer Rate
0.31
5/6572
0.76
51/402
126.87
0
N/A
10/20355
0.49
10/18843
0.53
0/5973
0.00
2.39
20/8375 *
1/2369
0.42
27.67
48/1735 *
5.97
50/8371 *
19.00
11/579 *
2/1457
1.37
1.81
40/22096 *
0.22
0.83
133.42
220.00
24.73
160.35
19.68
2/6357
33/150 *
73/2952
0.45
0.59
0.03
3.42
1.10
11.71
8.20
10.50
2.00
2.66
Facility rate > Peer group benchmark rate
◂ * Indicates that the rate i s s tatistically significantly different than the peer
• Report generated April 2013 AHRQ Patient Safety Indicators
Jan 12 – Dec 12
Data source: Premier
Greer, Hillcrest & Patewood Performance on AHRQ Safety Measures Patient Safety Indicators (Rate per 1 000)
Greer
Hillcrest
Patewood
Outcomes / Facility Rate
Discharges
Outcomes / Facility Rate
Discharges
Outcomes / Facility Rate
Discharges
Premi er Peer G roup
PSI 02 -­‐ Death i n Low Mortality DRGs
0/789
0.00
0/38
0.00
0/143
0.00
5.41
PSI 03 -­‐ Decubitus Ulcer
0/450
0.00
0/273
0.00
0/10
0.00
0.57
PSI 04 -­‐ Death i n Surgical Pts w Treatable Complications
0/15
0.00
0/19
0.00
0/9
0.00
117.23
PSI 05 -­‐ Foreign Body Left During Procedure ( Count)
N/A
N/A
N/A
PSI 06 -­‐ Iatrogenic Pneumothorax
0/2624
0.00
0/1,645
0.00
0/1,087
0.00
0.33
PSI-­‐07 -­‐ Central Line Associated Bloodstream Infection
0/2392
0.00
0/1,173
0.00
0/728
0.00
0.51
PSI 08 -­‐-­‐ Postoperative Hip Fx
0/277
0.00
0/403
0.00
0/94
0.00
0.02
PSI 09 -­‐ Postop Hemorrhage or Hematoma
1/877
1.14
2/671
2.98
1/1,072
0.93
2.19
PSI 10 -­‐ Postop Physiologica nd Metabolic Derangement
0/344
0.00
0/244
0.00
0/514
0.00
0.56
PSI 11 -­‐ Postop Respiratory Failure
3/340
8.82
2/245
8.16
2/507
3.94
9.85
PSI 12 -­‐-­‐ Postoperative PE or DVT
1/878
1.14
4/672
5.95
1/1,074
0.93
4.52
PSI 13 -­‐-­‐ Postoperative Sepsis
0/29
0.00
0/16
0.00
0/16
0.00
12.75
PSI 14 -­‐ Postop Wound Dehiscence 0/73
0.00
0/77
0.00
0/6
0.00
1.97
PSI 15 -­‐ Accidental Puncture or Laceration
2/2699
0.74
2/1,687
1.19
1/975
1.03
2.07
PSI 17 -­‐ Birth Trauma Injury to Neonate
2/661
3.03
2.08
PSI 18 -­‐ OB Trauma V aginal Delivery with Instrument
2/25
80.00
139.86
PSI 19 -­‐ OB Trauma V aginal Delivery without Instrument
9/465
19.35
16.70
Jan '12 -­‐ Dec '12 (Rolling 1 2 months)
Facility rate > Peer group benchmark rate
*
Indicates that the rate i s s tatistically s ignificantly higher than the peer
• Report generated April 2013 Agency for Healthcare Research and Quality (AHRQ) Pa-ent Safety Indicator #15 – Accidental Puncture & Lacera-on Greenville Memorial Hospital, data through Sept. 2012 Benchmark: Assoc. of American Medical Colleges–Council of Teaching Hospitals with > 500 Beds (62 like hospitals) Data source: University HealthSystem Consor]um Clinical Data Base/Resource Manager 1. LSS Team Ini-ated 2. Daily query of cases all special-es. •  MD/Coding review for GYN cases. •  Coder educa-on ini-ated . • Report generated April 2013 Agency for Healthcare Research and Quality (AHRQ)
Patient Safety Indicator #3 – Pressure Ulcers
reported in rolling 12-month increments
Pressure Ulcers-­‐ stages III, IV, or unstageable Observed Rate per 1,000 Cases 1.4 Greenville Memorial Peer Aggregate (62 like hospitals) 1.2 1.0 0.8 GMH trendline 0.6 0.4 Lower numbers reflect
better performance
0.2 0.0 OCT 08 -­‐ SEP 09 JAN 09 -­‐ DEC 09 APR 09 -­‐ MAR 10 JUL 09 -­‐ JUN10 OCT 09 -­‐ SEP 10 JAN 10 -­‐ DEC 10 APR 10 -­‐ MAR 11 JUL 10 -­‐ JUN 11 OCT 10 -­‐ SEP 11 JAN 11 -­‐ DEC 11 APR 11 -­‐ MAR 12 JUL 11 -­‐ JUN 12 OCT 11-­‐ SEP 12 Benchmark: Assoc. of American Medical Colleges -­‐ Council of Teaching Hospitals with > 500 Beds, who submit data to the University HealthSystem Consor]um (UHC) Clinical Data Base/Resource Manager JAN 12 -­‐ DEC 12 Safety Events
Number of Root Cause Analyses = 9
Top 10 HFACS Codes
1.  Communication:
a.  Inadequate / untimely;
b.  Inadequate report;
c.  Inadequate between providers.
2.  Routine violation of policy/procedure.
3.  Decision error:
a.  Wrong response to urgent situation;
b.  Selected incorrect procedure;
c.  Failure to prioritize task;
d.  Misinterpretation of information.
4.  Adverse mental state, task overload.
5.  Exceptional violation of policy/procedure.
Timeframe: January, 2013 through March, 2013
• Report generated April, 2013 CMS Healthcare Acquired
Conditions (HACs)
Retained Foreign Object 0
0
0
0
0
Baptist Easley 0
Air Embolism 0
0
0
0
0
0
Blood Incompatability 0
0
0
0
0
0
Pressure Ulcers 4
0
0
0
4
0
Falls / Trauma 8
1
0
0
9
1
Poor Glycemic Control 3
0
0
0
3
1
GMH Greer HMH PMH GHS Note: See Infec]ons for CLABSI and CAUTI Hospital Inpatient Quality Reporting Program (CMS HIQRP)
Publicly Reported Hospital-Acquired Conditions (HAC)
July 2009 – June 2011
Ra te i s ca l cul a ted p er 1,000 d i s cha rges
Foreign object retained after surgery
GMH
Greer
Hillcrest
Patewood
CMS (National)
1
0
0
0
640
El i gi bl e D i s cha rges
23081
2779
1644
1093
22,940,805
Foreign object Rate
0.043
0.000
0.000
0.000
0.028
0
0
0
0
66
Air e mbolism
El i gi bl e D i s cha rges
23081
2779
1644
1093
22,940,805
Air e mbolism Rate
0.000
0.000
0.000
0.000
0.003
Blood i ncompatibility
0
0
0
0
24
El i gi bl e D i s cha rges
23081
2779
1644
1093
22,940,805
Blood incompatibility Rate
0.000
0.000
0.000
0.000
0.001
0
0
0
0
3113
Pressure ulcer stages III and IV
El i gi bl e D i s cha rges
23081
2779
1644
1093
22,940,805
Pressure ulcer Rate
0.000
0.000
0.000
0.000
0.136
Falls and trauma*
11
1
1
0
12089
El i gi bl e D i s cha rges
23081
2779
1644
1093
22,940,805
Falls and Truama Rate
0.477
0.360
0.608
0.000
0.527
Vascular catheter-­‐associated i nfection
7
0
0
0
8532
El i gi bl e D i s cha rges
23081
2779
1644
1093
22,940,805
Vasc cath-­‐assoc infection Rate
0.303
0.000
0.000
0.000
0.372
21
0
0
0
8216
Catheter-­‐associated UTI
El i gi bl e D i s cha rges
23081
2779
1644
1093
22,940,805
CAUTI Rate
0.910
0.000
0.000
0.000
0.358
Manifestations of poor glycemic control
2
0
0
0
1320
El i gi bl e D i s cha rges
23081
2779
1644
1093
22,940,805
Poor glycemic control Rate
0.087
0.000
0.000
0.000
0.058
• Report generated July 2012 CMS
Partnership for Patients
Safety Events
•  Opportunities for Improvement
– 
– 
– 
– 
Communication and Handoffs
Safety Culture - Work Arounds
Decision Based Errors / Decision Making
Pressure Ulcers / Falls
•  Improvements
– 
– 
– 
– 
– 
Increased Occurrence Reporting / PSN Implementation
Development of HFACS RCA Process - Taught Medical Students
Lean Six Sigma Teams for Pressure Ulcers / Falls
Development of Metrics for Medication Delivery Process
Surgical Safety Checklist
SCHA / TJC Safe Care
Initiative
•  Collaborative Effort Across SC
–  AnMed, Baptist Easley, Georgetown, GHS, MUSC, Palmetto
Health, Roper St. Francis, VA Medical Center
•  Partner with TJC Center for Transforming Healthcare
•  3 Year Effort to Learn How to Go From Low Reliability to
High Reliability
•  Initial Efforts
–  Leadership Development (Presidents, Nursing Leaders, QM)
–  Tools (HRST / Safety Culture Survey / SSER)
•  Coordinator Based at GHS
•  Research (HSSC) Component Based at GHS
Alaris Guardrails® Suite Usage
GHS goal = 70% • Report generated April, 2013 Alaris Guardrails® Overrides
* Overrides per 1,000 infusion starts, 4/1/2012 through 3/31/ 2013 • Report generated April, 2013 Alaris Guardrails® Good Catches
26 Severe Poten]al Adverse Drug Events ]mes $ 8750. Current Period: 03/01/2013 – 03/31/2013; Previous Period: 02/01/2013 – 02/28/201.3 Infection Prevention and
Control
Hand Hygiene
Surgical Site Infections
CLABSI / VAP / CAUTI
MDRO (MRSA / C. Difficile)
GHS Overall Weighted Hand
Hygiene Compliance Rates
• Report generated April 2013 Hand Hygiene Compliance Rates
Baseline Hand Hyg Rate
GHS
Overall
Correct HH
Weighted
53.8%
Hand Hyg Rate
GMMC
(GMH, MIP,
Correct HH
RCP)
Observations
50.7%
Greer
Memorial
Hospital
Hand Hyg Rate
64.5%
Hillcrest
Memorial
Hospital
Hand Hyg Rate
North
Greenville
LTACH
Hand Hyg Rate
Patewood
Memorial
Hospital
Hand Hyg Rate
Observations
Correct HH
Observations
Correct HH
Observations
Correct HH
Observations
Correct HH
Observations
659
1222
305
601
51
79
65.0%
139
214
73.4%
138
188
94.3%
132
140
Oct-­‐Dec Jan-­‐Mar Apr-­‐Jun 2009 2010 2010 Jul-­‐Sep Oct-­‐Dec 2010 2010 Jan-­‐Jun 2011 Jul-­‐Dec Jan-­‐Mar Apr-­‐Jun 2011 2012 2012 Jul-­‐Sep 2012 Oct-­‐Dec Jan-­‐Mar 2012 2013 72.6%
85.2%
90.6%
92.2%
93.3%
93.7%
615
847
66.4%
95
143
97.0%
224
231
89.7%
96
107
86.4%
153
177
100%
128
128
KEY
80.0%
5773
7213
78.3%
4245
5419
82.6%
739
895
80.9%
161
199
91.6%
229
250
93.3%
70
75
< 60%
86.2%
6022
6990
86.2%
4010
4653
84.7%
439
518
87.8%
173
197
94.6%
123
130
91.8%
225
245
3879
4552
85.5%
2824
3304
79.9%
306
383
84.3%
220
261
89.3%
225
252
84.4%
205
243
87.2%
4220
4837
86.6%
2918
3370
95.7%
509
532
86.8%
401
462
93.4%
183
196
93.5%
259
277
60-69% 70-79% 80-89%
11066
12214
90.4%
7764
8591
93.0%
1221
1313
95.2%
1140
1198
91.9%
399
434
96.0%
623
649
10174
11037
91.8%
7110
7748
96.2%
1288
1339
91.5%
884
966
96.6%
365
378
95.4%
578
606
92.6%
4710
5085
92.8%
3268
3521
93.9%
611
651
95.9%
440
459
92.9%
171
184
98.1%
265
270
91.8%
4546
4954
91.8%
4538
4864
93.1%
3071
3344
93.3%
3086
3315
96.0%
624
669
93.5%
625
651
93.9%
435
465
92.4%
418
445
96.8%
171
185
95.5%
180
186
95.1%
278
291
254
267
1549
1653
93.5%
1053
1126
93.0%
91.9%
1513
1646
91.1%
1014
1113
96.8%
200
215
99.3%
214
221
91.7%
151
152
93.5%
143
156
96.8%
58
62
98.0%
61
63
92.5%
96
98
90-­‐100% • Report generated April 2013 86
93
Hand Hygiene Compliance Rates
by Type of Opportunity
• Report generated April 2013 Hand Hygiene
•  Germ Warfare: Join the Battle
–  3 Year Organization Wide Effort to Implement 5 Moments Hand
Hygiene Across System
–  Converting from Observed Observation to Electronic Data
Collection
•  Next Phase Approach
– 
– 
– 
– 
– 
– 
TJC Center for Transforming Healthcare
Targeted Solutions Tool
Identify Specific Root Causes on Individual Units
Units Design Improvement Methods
Pilot on 2C, 4C, 5C
Beta testing portable alcohol dispensers with monitoring
capability at patient bedside.
Infections (Jan-Mar 2013)
CLABSI VAP CAUTI MRSA C. Difficile Total GMH 8 5 44 16 50 123 Greer 0 0 1 2 0 3 Hillcrest 0 0 0 1 0 1 NGMH 0 0 5 3 1 9 Patewood 0 0 0 0 0 0 GHS 8 5 50 22 51 136 Bapt. Easley Surgical Site Infections
Better than Expected (Colon Resection, Small Bowel, Ventral
Hernia, C-Section)
Worse than Expected (Hip Replacement)
GHS Surgical Site
Infections
GHS Surgical Site Infections
GHS System-­‐Wide (GMH, PMH, GrMH, HMH) Surgical Site Infec-ons (Jan 1, 2012 – Dec 31, 2012) Sta-s-cally Standardized 95% Lower 95% Upper Expected Infec-on Ra-o Confidence Confidence Sta-s-cal Significance Infec-ons (SIR) Limit Limit Observed Infec-ons Total Surgeries CABG (Chest and Donor)* 3 355 10.10 0.30 0.08 0.81 Lower than expected Abdominal Hysterectomy* 8 616 10.74 0.75 0.35 1.41 Not different than expected Hip Replacement* 19 651 10.16 1.87 1.16 2.87 Higher than expected Knee Replacement* 5 695 5.78 0.87 0.32 1.92 Not different than expected Colon Resec-on 8 419 26.7 0.30 0.14 0.57 Lower than expected Bariatric Surgery 5 175 3.99 1.25 0.46 2.78 Not different than expected Small Bowel 8 313 19.06 0.42 0.20 0.80 Lower than expected Ventral Hernia 7 477 10.78 0.65 0.28 1.29 Not different than expected C-­‐Sec-on 24 2013 37.02 0.65 0.42 0.96 Lower than expected TOTAL All Sites 87 5715 134.3 0.65 0.52 0.80 Lower than expected Surgical Site Sta]s]cally Expected Infec]ons Based on NHSN Data; Standardized Infec]on Ra]o (SIR) = Observed Infec]ons / Expected Infec]ons 95% Confidence Limits = The Confidence Interval provides the range in which the TRUE SIR will fall 95% of the ]me * New risk adjustment methodology
• Report generated January 2013 Surgical Site Infections
Surgical Site Infec-on Rates: Jan 1, 2012 – Dec 31, 2012 Greenville Memorial Hospital Observed Infec-ons Surgeries Sta-s-cally Expected Infec-ons CABG* 3 355 10.10 0.30 0.08 0.81 Lower than expected Hip Replacement* 10 140 4.21 2.38 1.21 4.23 Higher than expected Knee Replacement* 0 5 0.10 0.00 0.00 36.9 Not different than expected Abdominal Hyst* 8 607 10.59 0.76 0.35 1.44 Not different than expected Ventral Hernia 7 477 10.78 0.65 0.28 1.29 Not different than expected Small Bowel 8 313 19.06 0.42 0.20 0.80 Lower than expected Colon Resec-on 8 391 25.13 0.32 0.15 0.61 Lower than expected C-­‐Sec-on 23 1832 33.69 0.68 0.43 1.02 Not different than expected Type of Surgery Standardized Infec-on Ra-o (SIR) 95% Lower Confidence Limit 95% Upper Confidence Limit Sta-s-cal Significance Greer Memorial Hospital Sta-s-cally Expected Infec-ons Standardized Infec-on Ra-o (SIR) 95% Lower Confidence Limit 95% Upper Confidence Limit Sta-s-cal Significance 2.47 1.22 0.31 3.31 Not different than expected 176 1.67 0.00 0.00 2.21 Not different than expected 0 9 0.13 0.00 0.00 28.4 Not different than expected C-­‐Sec-on 1 181 3.33 0.30 0.02 1.48 Not different than expected Colon Resec-on 0 17 0.83 0.00 0.00 4.45 Not different than expected Observed Infec-ons 3 Surgeries 181 Knee Replacement* 0 Abdominal Hyst* Type of Surgery Hip Replacement* Sta]s]cally Expected Infecions -­‐ Based on NHSN Data Standardized Infec]on Ra]o (SIR) = Observed Infec]ons / Sta]s]cally Expected Infec]ons * New risk adjustment methodology
• Report generated January 2013 Surgical Site Infections
Type of Surgery Surgical Site Infec-on Rates: Jan 1, 2012 – Dec 31, 2012 Patewood Memorial Hospital Sta-s-cally Standardized 95% Lower 95% Upper Expected Infec-on Ra-o Confidence Confidence Observed (SIR) Limit Limit Infec-ons Surgeries Infec-ons Sta-s-cal Significance Hip Replace* 5 265 2.79 1.79 0.66 3.97 Not different than expected Knee Replace* 5 432 3.19 1.57 0.57 3.47 Not different than expected Type of Surgery Bariatric Surgery Hillcrest Memorial Hospital Sta-s-cally Standardized 95% Lower 95% Upper Sta-s-cal Significance Expected Infec-on Ra-o Confidence Confidence Observed (SIR) Limit Limit Infec-ons Surgeries Infec-ons 5 175 3.99 1.25 0.46 2.78 Not different than expected Hip Replace* 1 65 0.69 1.45 0.07 7.15 Not different than expected Knee Replace* 0 82 0.82 0.00 0.00 4.50 Not different than expected Colon Resec-on 0 11 0.71 0.00 0.00 5.20 Not different than expected Sta]s]cally Expected Infec]ons -­‐ Based on NHSN Data Standardized Infec]on Ra]o (SIR) = Observed Infec]ons / Sta]s]cally Expected Infec]ons * New risk adjustment methodology
• Report generated January 2013 GHS Adult CLABSI
[CY08 Q2 – CY13 Q1]
CLABSI Rate CLABSI Rate per 1000 Line Days 5.0 4.5 NHSN Pooled Mean NHSN Top 25th Percen]le 4.45 4.0 3.5 2.77 3.0 2.5 1.77 2.0 1.5 Oct: Non-­‐ICU Interven-on July: ICU Interven-on 1.0 1.79 1.23 0.91 0.5 0.57 0.22 0.0 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 2009 2008 Q2 Q3 Q4 Q1 2010 2009 Q2 Q3 Q4 Q1 2011 2010 Q2 Q3 Q4 2012 2011 Q1 2013 2012 2013 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 CLABSI 54 39 39 31 41 30 36 16 15 18 12 17 13 9 13 8 7 4 3 6 9033 8505 9061 9482 9515 8748 9618 9869 8763 9601 9818 9320 10520 Line Days 12140 11595 11585 11196 10604 10625 11190 Note: NHSN data from 2011 Report
• Report generated April 2013 GMH Adult CLABSI
Quarterly Rates Over Time [CY08 Q2 – CY12 Q2]
CLABSI Rate CLABSI Rate per 1000 Line Days 4.5 NHSN Pooled Mean Top 25th Percen]le 4.18 4.0 3.5 2.77 3.0 2.5 2.03 1.87 2.0 1.5 1.2 July: ICU Interven-on 1.0 0.84 Oct: Non-­‐ICU Interven-on 0.5 0.69 0.19 0.0 Q2 CLABSI Line Days Q2 Q3 2008 Q3 Q4 Q4 42 28 32 10039 9519 9374 Note: NHSN data from 2011 Report
Q1 Q1 Q2 Q3 2009 Q2 Q3 24 29 19 8665 8137 8345 Q4 Q1 Q2 Q3 2010 Q4 Q1 Q2 24 8704 13 6943 13 7143 Q3 Q4 Q4 15 12 7982 7982 Q1 Q1 16 7889 Q2 Q3 2011 Q2 Q3 Q4 Q4 8 9 10 7540 8173 8105 Q1 Q1 6 7114 Q2 Q3 2012 Q2 Q3 Q4 Q4 6 4 3 8020 8346 7964 Q1 2013 Q1 6 8733 • Report generated April 2013 CLABSI Prevention
Peds Intensive Care Unit CLABSI rate 2011-­‐March 2013 PICU CLABSI/1000 line days 6.0 NHSN pooled mean (1.8) 5.1 5.0 4.0 2012 rate= 1.5 [1/661] 3.0 2.0 1.3 1.0 0.0 0.0 Total 2011 CLABSI
Line days
Pt days
Utilization
Utilization pooled mean
Q1-­‐12 1
776
2224
0.35
0.47
Q2-­‐12 0
150
636
0.24
0.47
1
196
562
0.35
0.47
0.0 0.0 0.0 Q3-­‐12 Q4-­‐12 Q1-­‐13 0
185
547
0.34
0.47
0
130
567
0.23
0.47
0
168
658
0.26
0.47
On March 31st, PICU celebrated 303 days since last CLABSI!
• Report generated April 2013 CLABSI Prevention
Peds Med/Surg (5E/6E) CLABSI rate 2011-­‐March 2013 5E/6E CLABSI rate/1000 line days 6.00 NHSN pooled mean (1.2) 5.04 5.00 4.00 3.17 2012 rate= 2.06 [3/1454] 3.00 2.00 1.89 1.00 0.00 0.00 2011 CLABSI
Line days
Pt days
Utilization
Utilization pooled mean
Q1-­‐12 3
1585
10947
0.14
0.18
0.00 0.00 Q2-­‐12 0
367
3009
0.12
0.18
Q3-­‐12 1
315
2579
0.12
0.18
Q4-­‐12 0
375
2895
0.13
0.18
Q1-­‐13 2
397
3146
0.13
0.18
0
401
3245
0.12
0.18
• Report generated April 2013 CLABSI Prevention
Peds Heme/Onc CLABSI Rate (Perm. lines) 2011-­‐March 2013 NHSN pooled mean (1.7) Heme/Onc 3.5 CALBSI /1000 line days 3.0 2.5 2.0 2012 rate= 1.1 [2/1859] 2.3 1.8 1.7 1.61 Q4-­‐12 Q1-­‐13 1.5 1.0 0.5 0.0 0.0 Q2-­‐12 Q3-­‐12 0.0 2011 CLABSI
Line days
Pt days
Utilization
Utilization pooled mean
Q1-­‐12 3
1630
2222
0.73
0.62
1
432
657
0.66
0.62
0
388
665
0.58
0.62
0
461
598
0.77
0.62
1
578
828
0.70
0.62
1
622
836
0.74
0.62
• Report generated April 2013 CLABSI Prevention and
Cost-Savings (GHS Adult) *
Baseline Jul ‘08-­‐ Jun ‘09 CLABSI # Jul ‘09-­‐ Jun ’10 Jan ‘10-­‐ Dec ’10 Jan ‘11-­‐ Dec ’11 Jan ‘12-­‐ Dec ’12 % Improvement Baseline to Dec 2012 150 97 61 52 23 84.7% 44,980 39,353 36,081 37,872 37,385 16.9% Rate 3.33 2.46 1.69 1.37 0.62 81.4% NHSN Top Quar]le 0.26 0.26 0.26 0.26 0.26 -­‐-­‐-­‐ 12 10 9 10 10 -­‐-­‐-­‐-­‐ Excess CLABSI 138 87 52 42 13 90.6% NHSN Mean 1.66 1.66 1.66 1.66 1.66 -­‐-­‐-­‐-­‐ Expected CLABSI 75 65 60 63 62 -­‐-­‐-­‐-­‐ Excess 75 32 1 -­‐11 -­‐39 152% CLABSI Prevented -­‐-­‐-­‐-­‐-­‐ 53 89 98 127 Lives Saved (10-­‐20%) -­‐-­‐-­‐-­‐-­‐ 5-­‐10 9-­‐18 10-­‐20 13-­‐25 Cost Savings ($40,000/Case) -­‐-­‐-­‐-­‐-­‐ $2,120,000 $3,560,000 $3,920,000 $5,080,000 Line Days Expected CLABSI • Report generated January 2013 VAP Prevention and CostSavings GHS Adult
(using NHSN 2009 report)
CY 2007
Baseline
VAP #
CY
2008
CY
2009
CY
2010
CY
2011
CY
2012
% Improvement
Since Baseline to
Dec 2012
106
67
38
25
27
14
10,810
12,418
13,811
12,479
13,023
12,009
Rate
9.81
5.40
2.75
2.00
2.07
1.17
88.1%
NHSN Top 25%
0.20
0.20
0.20
0.20
0.20
0.20
-----
2
3
3
3
3
2
-----
Excess VAP
104
64
35
22
24
12
88.5%
NHSN Mean
2.49
2.49
2.49
2.49
2.49
2.49
-----
Expected VAP
27
31
34
31
32
30
-----
Excess
79
36
4
-6
-5
-16
120%
Since 2007
VAP Prevented
-----
39
68
81
79
92
Lives Saved
(~20-30%)
-----
8-12
14-20
16-24
16-24
18-28
-----
$1.56
$2.72
$3.24
$3.16
$3.68
Vent Days
Expected VAP
Cost Savings
In Millions
(@ $40,000/Case)
86.8%
-----
• Report generated January 2013 GHS Adult CAUTI
CAUTI Rate per 1000 Foley Cath Days Monthly Rates Over Time [Apr ’12 – Mar ’13]
CAUTI Rate 6.0 NHSN Top 25th Percen]le 5.29 5.0 4.0 NHSN Pooled Mean 4.52 3.98 3.71 3.0 2.0 1.64 1.0 0.26 0.0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan 2012 Feb Mar 2013 2012 2013 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar CAUTI 15 21 24 21 17 15 19 23 15 16 15 18 4044 4326 4257 4647 4614 4169 4369 4344 4527 4473 3835 4517 Foley Cath Days Note: NHSN data from 2011
• Report generated April 2013 GMH Adult CAUTI CAUTI Rate per 1000 Foley Cath Days Monthly Rates Over Time [Apr ‘12 – Mar ‘13] CAUTI Rate 7.0 NHSN Pooled Mean NHSN Top 25th Percen]le 6.0 4.97 5.0 4.0 4.46 4.30 3.90 3.0 2.0 1.58 1.0 0.21 0.0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan 2012 Feb Mar 2013 2012 2013 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar CAUTI 13 20 24 17 15 13 15 18 14 14 12 17 3334 3620 3617 3949 3747 3481 3529 3625 3760 3674 3059 3810 Foley Cath Days Note: NHSN data from 2011
• Report generated April 2013 GMH PICU CAUTI
per 1000 catheter days 2011 - 2012
PICU
CAUTI /1000 catheter days
20.00
NHSN pooled mean (2.2)
17.86
18.00
15.63
16.00
2012 Rate= 3.8 [2/520] 14.00
12.00
10.00
8.00
6.00
4.00
2.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12
Total CAUTI Catheter Days Pa-ent Days Device U-liza-on Ra-o 0 26 234 0.11 0 0 1 0 0 0 0 1 0 0 0 29 37 56 43 33 52 48 64 46 42 44 198 204 208 171 183 174 201 172 187 169 211 0.15 0.18 0.27 0.25 0.18 0.30 0.24 0.37 0.25 0.25 0.21 DU Pooled Mean 0.26 0.26 0.26 0.26 0.26 0.26 0.26 0.26 0.26 0.26 0.26 0.26 v Recommenda]ons/Ac]ons: Con]nue CAUTI surveillance; CAUTI educa]on board completed for unit; upcoming CAUTI educa]on. • Report generated April 2013 GMH MRSA
0.90 GMMC MRSA Facility Associated Infec-on Rate/ 1000 Pa-ent Days Total 2011-­‐ March 2013 0.80 Axis Title 0.70 0.60 0.50 0.40 0.30 MRSA Rate 0.20 MRSA Mean=0.39 0.10 MRSA Upper Warning=0.72 0.00 2011 Total Qt1-­‐12 Qt2-­‐12 Qt3-­‐12 Qt4-­‐12 Qt1-­‐13 MRSA Upper Contro=0.89 Yr/ Quarter
2011
Total
Qt1-12
Qt2-12
Qt3-12
Qt4-12
Qt1-13
MRSA HCA Infections
80
19
21
23
21
24
Patient Days
201578
51290
48750
51461
53090
51421
Rate/ 1000 pt days
0.40
0.37
0.43
0.45
0.40
0.47
North Greenville MRSA Infection Rate
per 1000 patient days 2011 – 2012
1.6
1.4
1.2
1
2012 Rate= 0.73 [6 / 8188] 0.8
MRSA Target (0.74) 0.6
0.4
0.2
0
2011 J -­‐ M 12 A -­‐ J 12 J -­‐ S 12 J -­‐ D 12 # 4 1 2 2 1 Pt Days 8950 2229 2018 2116 1825 • Report generated January 2013
GMH MRSA PCR Screening
Jan – Dec 2012
Total PCR Swabs
collected
Total Positive
PCR
Total Negative
PCR
25941
2037
23904
Percentage
8%
92%
• Report generated April 2013 GMH C-Difficile Infection Rate
GMH Clostridium difficile Facility-­‐Associated Infec-on/Coloniza-on Rate per 10,000 Pa]ent Days 2011-­‐March 2013 18.00 Rate/ 10000 pt days 16.00 14.00 2013 YTD= 9.72 [50/51421] 12.00 10.00 8.00 FA Mean=6.7 FA Upper Control Warning=12.4 6.00 4.00 FA Upper Control Limit=16.9 2.00 0.00 Total 2011 Qt 1 2012 Qt 2 Qt 3 Qt 4 2013 Qt 1 Year/ Quarter C diff HCA Coloniza]on/ Infec]on 2011 Q1-­‐Q4 116 Qtr 1 34 Qtr 2 18 2012 Qtr 3 37 Qtr 4 48 2013 Qtr 1 50 Pa]ent Days Rate/ 10000 pt days 201,578 5.75 51,290 6.63 48,750 3.69 51,461 7.19 53,090 9.04 51,421 9.72 *C. Diff PCR implemented in July 2012 and is indicated by arrow.
• Report generated April 2013 Combined Multi-Drug Resistant
Organisms (MDRO)
• Report generated January 2013
Infection Prevention
Highlighted Initiatives
January – March 2013
• 
VAP and CLABSI PI Teams
– 
– 
– 
Monitor infections
Conduct root cause on infections
Implemented CHG bathing in targeted locations to reduce
CLABSI rates.
•  Catheter Associated UTI Process Improvement
–  Address Appropriateness of Foley Catheter Use
–  CAUTI Basic training for educators
–  Front line staff education initiated
–  Hip Joint SSI Prevention
–  Work groups on PMH and GMMC campuses focusing on SSI
reduction. MD leadership involvement.
Infection Prevention
Highlighted Initiatives
January – March 2013
•  NBICU Infection Prevention
–  Joined Ohio Children’s Hospital Solutions for Patient
Safety initiative: infection Prevention Initiated VAP and SSI
surveillance for GHS Children’s Hospital.
•  MDRO Prevention
–  Environment of Care: Monitoring using quantitative
methods (Clean Trace, Dazo) to improve environmental
hygiene.-Collaborative with Environmental Services and pt
care locations.
–  Expanded Precautions Monitoring for compliance with
precautions, hand hygiene, documentation.
–  Hand Hygiene: Continue efforts to transition to electronic
Monitoring.
–  Work Out session led to modified process to improve collecting
MRSA PCR on pt admission. Process is working on pilot units.
Plans are underway to spread to all other GMMC units.
Questions?
Value Based Purchasing
Clinical Core Measures
Baptist Easley Hospital– Year 2
Quality Measure Performance Report
Value Based Purchasing Clinical Measures
CFG/Population - Measure
BAPTIST EASLEY
Apr - Dec 12
Num
Den
Rate
VBP
Achievement
Score
VBP
Improvement
Score
Threshold
Score
CMS
Benchmark
Score
0 - 10
0-9
Rate
Rate
IP AMI
IP AMI
Fibrinolytic Therapy Received Within 30 Minutes
0
0
NA
NA
Primary PCI Received Within 90 Minutes
0
0
NA
NA
IP AMI
NA
NA
80.66%
93.44%
4
92.66%
IP HF
IP HF
Discharge Instructions
123
124
99.19%
9
IP PN
IP HF
IP PN
Blood Cultures Performed Prior to Initial Abx in ED
Antibiotic Selection
195
121
195
124
100.00%
97.58%
10
6
100.00%
IP PN
9
0
97.30%
94.46%
IP SCIP
IP SCIP
96.30%
100%
100.00%
100.00%
IP SCIP
Received BB During Perioperative Period
110
110
101
125
48
110
110
102
127
48
100.00%
100.00%
99.02%
98.43%
100.00%
10
10
7
8
10
9
9
8
2
9
98.07%
98.13%
96.63%
92.86%
95.65%
100.00%
100.00%
99.96%
99.89%
100.00%
Recommended Venous Thromboembolism Prophylaxis
Ordered
154
154
100.00%
10
9
94.62%
100.00%
Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru
24 hrs after Surg
153
154
99.35%
9
9
94.92%
99.83%
89 out of
possible
100 points
68
improvement
points
Prophylactic Antibiotic Timing
Prophylactic Antibiotic Regimen
Prophylactic Antibiotic discontinued within 24 hrs post op
Urinary Catheter Removed Post op Day 1 or 2
GrMH VBP Composite Score
1240 1248 99.36%
90.00%
Greer Memorial Core Measure Domain Score
≥ Target Score of 98%
< Target Score of 98%
Threshold = Median score among all hospitals during baseline period
Benchmark = Mean of the top decile
• Report generated April 2013 All Care Measures –
Baptist Easley Hospital
Facility
Jan 12
Feb 12
Mar 12
Apr 12
May 12
Jun 12
Jul 12
Aug 12
Rolling 12
Months:
Dec 12
Jan 12Dec 12
Sep 12
Oct 12
Nov 12
96.7%
100.0%
96.6%
97.5%
98.3%
100.0%
100.0%
100.0%
100.0%
99.1%
100.0%
97.2%
98.1%
98.5%
INPATIENT MEASURES
Baptist
Easley
100.0%
96.2%
100.0%
100.0%
100.0%
95.9%
98.5%
97.7%
OUTPATIENT MEASURES
Baptist
Easley
100.0%
100.0%
100.0%
100.0%
100.0%
91.3%
100.0%
100.0%
INPATIENT AND OUTPATIENT MEASURES
Baptist
Easley
100.0%
97.1%
100.0%
100.0%
100.0%
94.4%
98.9%
98.5%
97.3%
Performing at or above FY11 Organizational target of 93.0%
• Report generated April 2013 Mortality & Readmission
Baptist Easley Hospital
Mortality Rate
Facility
Easley Baptist
CY 2011
Q1 2012
Q2 2012
Q3 2012
Q4 2012
CY 2012
Mortality Mortality Rate Rate Index
Mortality Mortality Rate Rate Index
Mortality Mortality Rate Rate Index
Mortality Mortality Rate Rate Index
Mortality Mortality Rate Rate Index
Mortality Mortality Rate Rate Index
1.66%
0.49
1.75%
0.57
2.29%
0.72
1.46%
0.58
2.38%
0.99
1.96%
0.70
Readmission Rate Within 30 days
Facility
Easley Baptist
CY2011
Q1 2012
Q2 2012
Q3 2012
Q4 2012
CY 2012
Readmit Readmit Rate
Rate Index
Readmit Readmit Rate
Rate Index
Readmit Readmit Rate
Rate Index
Readmit Readmit Rate
Rate Index
Readmit Readmit Rate
Rate Index
Readmit Readmit Rate
Rate Index
9.03%
0.77
8.96%
0.78
9.55%
0.82
7.09%
0.62
8.00%
0.70
8.90%
0.77
Observed rate is significantly ≤ than Expected (O/E ratio ≤ 1.0 and statistically significant)
The ratio of Observed to Expected Mortality is ≤ 1 but not statistically significant (O/E ratio ≤ 1.0)
The ratio of Observed to Expected Mortality is > 1 but not statistically significant (O/E ratio > 1.0)
Observed rate is significantly > than Expected (O/E ratio > 1.0 and statistically significant)
• Report generated April 2013 
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