patient safety metrics
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CLINICAL PERFORMANCE AND EMPLOYEE SAFETY METRICSExecutive Dashboard
NIH Clinical Center
October 2017
Patients’ Perceptions• Overall Hospital Rating• Would you Recommend the NIH CC?
50
55
60
65
70
75
80
85
90
95
100
Qtr 1 2016 Qtr 2 2016 Qtr 3 2016 Qtr 4 2016 Qtr 1 2017 Qtr 2 2017
Per
cen
t P
osi
tive
Sco
reOverall Hospital Rating
Overall Rating of Hospital - Inpatient Overall Rating of Hospital - Outpatient
NRC Benchmark (Inpatient) CMS HCAHPS Benchmark (Inpatient)
50
55
60
65
70
75
80
85
90
95
100
Qtr 1 2016 Qtr 2 2016 Qtr 3 2016 Qtr 4 2016 Qtr 1 2017 Qtr 2 2017
Per
cen
t P
osi
tive
Res
po
nse
Would You Recommend the NIH CC?
Would Recommend Hospital - Inpatient Would Recommend Hospital - Outpatient
NRC Benchmark (Inpatient) CMS HCAHPS Benchmark (Inpatient)
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%
2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2 2017-Q3
Per
cen
t A
dh
eren
ce
Hand Hygiene Adherence
Data collected by Unit-based
Data collected by Independent Auditors
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2
Infe
ctio
ns
per
10
00
cat
het
er d
ays
Whole-house Central-Line Associated Bloodstream Infection (CLABSI) Rate
n=7n=6
n=6
0.00
2.00
4.00
6.00
8.00
10.00
12.00
2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2
Infe
ctio
ns
per
10
00
cat
het
er d
ays
ICU Central-Line Associated Bloodstream Infection (CLABSI) Rate
ICU CLABSI Rate NHSN ICU Benchmark
n=1
n=1n=1
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2 2017-Q3
Infe
ctio
n p
er 1
00
0 f
ole
y d
ays
ICU Catheter-Associated Urinary Tract Infections
ICU CAUTI Rate NHSN ICU Benchmark
n=1
0.00
2.00
4.00
6.00
8.00
10.00
12.00
2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017Q1 2017-Q2
Infe
ctio
ns
per
10
00
cat
het
er d
ays
Surgical Oncology Catheter-Associated Urinary Tract Infections
Surgical Oncology NHSN Benchmark
0
0.5
1
1.5
2
2.5
3
3.5
2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2
Infe
ctio
ns
per
10
0 P
roce
du
res
Surgical Site Infections (SSI) Rate
SSI Rate Clinical Center Average
Nursing Quality Metrics • Falls• Pressure Injury• Medication Administration Barcoding
0
0.5
1
1.5
2
2.5
3
3.5
2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2
Falls
per
10
00
pat
ien
t d
ays
Inpatient Falls Rate
Falls Rate NDNQI Benchmark
0%
1%
2%
3%
4%
5%
6%
2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2 2017-Q3
% o
f Su
rvey
ed P
atie
nts
wit
h H
osp
ital
-Acq
uir
ed P
ress
ure
Inju
ries
Pressure Injury Prevalence
CC Mean National Mean (NDNQI)
The uptick in pressure injuries is largely due to injuries associated with long complex operative cases. An
interdisciplinary team (nursing, surgery, anesthesia, wound care) reviewed OR positioning practices, use of
compression stockings, oral breakdown related to endotracheal tubes, etc..
90%
91%
92%
93%
94%
95%
96%
97%
98%
99%
100%
Med
icat
ion
Bar
cod
ing
Use
(%
)Knowledge Based Medication Administration (KBMA)
Medication Barcoding Usage Report
% KMBA Used Goal
Emergency Response• Code Blue and Rapid Response
• Types of Patients• Type of Event• Patient Disposition
16-Qtr 4 17-Qtr 1 17-Qtr 2 17-Qtr 3 Total
Inpt 10 15 21 12 58
Outpt 12 9 11 13 45
Employee 14 16 8 9 47
Visitor 3 2 3 4 12
Incorrect Calls 0 0 0 0 0
0
20
40
60
80
100
120
140
160
180N
um
be
r
Code Blue Response: Types of "Patients"
16-Qtr 4 17-Qtr 1 17-Qtr 2 17-Qtr 3 TOTAL
Arrest 1 2 5 2 10
Acute Emergency 14 14 10 9 47
Stable Event 25 26 28 27 106
0
20
40
60
80
100
120
140
160
180N
um
be
r
Code Blue Response: Type of Event
16-Qtr 4 17-Qtr 1 17-Qtr 2 17-Qtr 3 TOTAL
Transfer to ICU 12 10 14 7 43
Transfer to OSH 13 15 8 10 46
Remained on Unit 4 6 14 13 37
Expired 1 1 1 0 3
Released 3 2 2 1 8
Other 7 8 4 7 26
0
20
40
60
80
100
120
140
160
180N
um
be
r
Code Blue Response: Patient Disposition
16-Qtr 4 17-Qtr 1 17-Qtr 2 17-Qtr 3 Total
ICU 5 7 11 8 31
Unit/Other 1 0 1 0 2
Remained on Unit 5 10 14 13 42
0
10
20
30
40
50
60
70
80N
um
be
r
Rapid Response Team: Patient Disposition
Blood and Blood Product Use• Crossmatch to Transfusion (C:T) Ratio• Transfusion Reaction by Class• Unacceptable Blood Bank Specimens
0
0.5
1
1.5
2
2.5
2015_Q4 2016_Q1 2016_Q2 2016_Q3 FY2016_Q4 FY2017_Q1 FY2017_Q2 FY2017_Q3
Cro
ssm
atch
to
Tra
nsf
use
d U
nit
s R
atio
Crossmatch to Transfusion (C:T) Ratio
C:T Ratio CC C:T Ratio Goal
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.
0.000
0.001
0.002
0.003
0.004
0.005
0.006
0.007
0.008
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
FY2015 FY2016 FY2017
Per
cen
t o
f Tr
ansf
usi
on
sTransfusion Reactions by Class
Anaphlactic and Other Febrile, Non Hemolytic Hemolytic, Septic, Anaphlactoid, and TRALI
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sept-17
Per
cen
t u
nac
cep
tab
le s
pec
imen
s
Unacceptable Blood Bank Specimens
Percent specimens with collection problems CC Threshold
Clinical Documentation• Medical Record Completeness
• Delinquent Records• “Agent for” Countersignature Adherence• Unacceptable Abbreviation Use
• Accuracy of Coding
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17
% r
eco
rds
del
inq
uen
t af
ter
30
day
sDelinquent Records
(>30 days post discharge)
Joint Commission Benchmark Delinquent Records
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% v
erb
al o
rder
s si
gned
in 7
2 h
ou
rs
"Agent for" Orders Countersignature Compliance
% of Compliance CC Goal
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2014-Q1 2014-Q2 2014-Q3 2014-Q4 2015-Q1 2015-Q2 2015-Q3 2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2 2017-Q3
% a
pp
rop
riat
e u
se o
f ab
bre
viat
ion
s"Do Not Use" Abbreviation Adherence
Compliance with Abbreviation Use CC Goal
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
2014-Q1 2014-Q2 2014-Q3 2014-Q4 2015-Q1 2015-Q2 2015-Q3 2015-Q4 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2
% a
ccu
racy
of
cod
ing
Accuracy of Record Coding
Accuracy of Coding CC Goal
New staff on-board;
transitioning to ICD-10
Employee Safety • Occupational Injury and Illness
0
5
10
15
20
25
30
35
40
TRC ORC DAFW DJTR DART
NU
MB
ER O
F C
ASE
S
OSHA CLASSIFICATIONS
Comparison of Occupational Injuries and Illnesses for CC Employees: 1st and 2nd Quarter 2017
1QTR 2QTR
• Two-thirds of M/S cases (12/18) occurred in Pharmacy.
• Eight M/S cases occurred in the new Intravenous Admixture Unit (IVAU)
• Total Recordable Cases (TRC) spiked with an increased number of Other Recordable Cases (ORC)
• Musculoskeletal trauma (M/S) without patient contact remains the most common OI
• Injuries in IVAU include repetitive motion injuries as well as body mechanics issues
• Hospital Safety and Occupational Medicine are working with IVAU staff to address ergonomic issues
52%
30%
9%
9%
Types of Occupational Injuries Reported in 2nd Quarter 2017 n=34
M/S Trauma Wounds ERGO Other
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