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Hospital Board Report

Hospital Board Report. Your logo here. Updated 6/30/2008. Overall Mortality Rate. This graph measures mortality (death) rate for inpatients. It is calculated as: “RATE” = number of patient deaths divided by number of inpatient discharges x100

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Hospital Board Report

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  1. Hospital Board Report Your logo here Updated 6/30/2008

  2. Overall Mortality Rate • This graph measures mortality (death) rate for inpatients. It is calculated as: “RATE” = number of patient deaths divided by number of inpatient discharges x100 • All deaths are reviewed for opportunities to improve. • Mortality should be 2% or less. • LOWER numbers are better. Action Plan: Increase use of Rapid Response Teams by 50%

  3. IHI/CMS Hospital Measurement: Mortality Measures Action Plan: We have set as a goal to be below the national average on both measures by end of year 2008. Hospital Compare: Jul 06 – Jun 07

  4. IHI/CMS Hospital Measurement: Acute Myocardial Infarction (Heart Attack) Action Plan: We have set as a goal to be at the rate of the top 10% of hospitals by end of year 2008. Hospital Compare: Jul 06 – Jun 07

  5. Our Hospital Trend: Acute Myocardial Infarction (Heart Attack)

  6. CMS Hospital Measurement: Pneumonia Action Plan: We have set as a goal to be at the rate of the top 10% of hospitals by end of year 2008. Hospital Compare: Jul 06 – Jun 07

  7. Our Hospital Trend:Pneumonia

  8. CMS Hospital Measurement: Heart Failure Action Plan: We have set as a goal to be at the rate of the top 10% of hospitals by end of year 2008. Hospital Compare: Jul 06 – Jun 07

  9. CMS Hospital Trend: Heart Failure

  10. CMS Hospital Measurement: Surgical Site Action Plan: We have set as a goal to be at the rate of the top 10% of hospitals by end of year 2008. Hospital Compare: Jul 06 – Jun 07

  11. Our Hospital Trend: Surgical Site Infection

  12. CMS Hospital Measurement: Patients’ Perception of Care Action Plan: We have set as a goal to be at the rate of the top 10% of hospitals by end of year 2008. Hospital Compare: Jul 06 – Jun 07

  13. Our Hospital Trend: Patients’ Perception of Care

  14. Our Hospital Trend: Patients’ Perception of Care

  15. Ventilator Associated Pneumonia • This graph measures the number of ventilator associated pneumonia. “RATE” = number of ventilator associated pneumonia divided by number of inpatient discharges x1000 • Review graph for upward trend. • LOWER numbers are better. Action Plan: Be below 2% by January 2009

  16. Central Line Infections • This graph measures the number of central line infections “RATE” = number of central line infections divided by number of inpatient discharges x1000 • Review graph for upward trend. • LOWER numbers are better. Action Plan: Be below 2% by January 2009

  17. # of Rapid Response Team Calls • This graph measures the number of rapid response team calls. • Review graph for upward trend. (We are implementing rapid response teams so our scores started at zero.) • HIGHER numbers are better. Action Plan: Be above 30 by 2Q08

  18. Hand Hygiene • This graph measures the number of times hand hygiene occurred per patient day. • Review graph for upward trend. (It is not unusual for hospitals to begin the trend below 20.) • HIGHER numbers are better. Action Plan: Be above 30 by July 2008 and at 60 by January 2009

  19. % of Unreconciled Medications • This graph measures the percent of unreconciled medications. • Review graph for downward trend. (Most hospitals started at 100%.) • LOWER numbers are better. Action Plan: Reduce percent of unreconciled medications by 75 percent by 2Q09

  20. Patient Falls • This chart displays the patient falls rate. RATE = number inpatient falls divided by number of inpatient days x1000 • LOWER numbers are better. Falls/1000 Pt Days Action Plan: Rates were high in early 2007 and were reduced through a assessment by nursing of risk of fall on all patients at admission.

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