Page 17 - Thompson-Health-AR2013

Patient Safety is Our First Priority
Quality Indicators
Quality

Designations

Aggregated Medical Surgical & ICU data for
Hospital-Acquired Pressure Ulcers (Percent DAYS DAYS DAYS
of Surveyed Patients with Hospital Acquired SINCE OUR SINCE OUR LAST
SINCE OUR

Pressure Ulcers)
LAST FALL!
PRESSURE ULCER!
LAST INFECTION!

Tips for Tips for Tips for
8
Preventing Falls
Preventing Ulcers
Preventing Infections
6
9 Hourly Rounding 9 Turn and Position 9 Handwash

9 Reactivating Bed
q2Hours
9 Isolation Precaution 4
Alarms
9 Elevate Heels off Bed
9 Clean Equipment
2
9 Prompt Response 9 Braden Assessment
9 Patient / Family 0
to Call Bells and 9 Attend Use - Fitted Education
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
Bed Bells
Properly, Changed, 2011 2012 2013

9 Fall Huddles
is it Necessary?
Aggregated Medical/Surgical and ICU falls
per 1,000 Patient Days Compared to Magnet
Patient Safety is Our First Priority
Hospitals (Total Falls Per 1,000 Patient Days)
Patients are being encouraged to take an active role in their own safety.
30
Thompson’s “visual management boards” publicly display days since last fall,
pressure ulcer and infection in an effort to partner with our patients to decrease 25

hospital-acquired events and improve patient care. We recognize the crucial role 20
of patients’ perspectives in establishing a culture of safety. We are committed to
engaging patients and their families in the design and nurturing of safety efforts 15
10
while emphasizing transparency through the use of our boards.
5

0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
Core Measures
2011 2012 2013

Process of Care (Evidence-Based Medicine)
Aggregated Central Line Associated Blood
Stream Infections (Central Line Associated Blood
2010
2011
2012
2013
stream Infections per 1,000 Central Line Days)
Pneumonia Care
2.5
Pneumonia Care Composite
93%
97%
98%
98%
2
Includes blood culture drawn prior to antibiotic administration; appropriate antibiotic
1.5
use; inluenza and pneumococcal vaccine administration.
1
Heart Failure Care
0.5
Heart Failure Composite
93%
97%
99%
96%
0
Includes all elements of discharge instruction provided; left ventricular function assess; Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
ace inhibitor prescribed for heart failure.
2011 2012 2013

Stroke Care
Ventilator-Associated Pneumonias per
NYS Stroke Care Composite
96%
93%
97%
94%
1,000 Ventilator Days (ICU VAP per 1,000
IV TPA addressed within 2 hours of arrival if indicated; antithrombotic therapy; blood Ventilator Days)
clot prevention managed; blood clot prevention with atrial ibrillation; smoking cessation
addressed; lipid lowering medications addressed; swallowing evaluation completed; 2.5

rehabilitation considered; NIHSS completed on admission or discharge.
2
Surgical Infection Prevention
1.5

Surgical Infection Prevention 96%
98%
99.5%
99%
1
Composite
0.5
Includes appropriate antibiotic given within one hour of incision; appropriate hair
removal; appropriate medications indicated for blood clot prevention; indications for
beta blocker addressed preoperatively; antibiotics appropriately discontinued; urinary Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
0
catheter removed by post-op day 2; pre-operative temperature managed.
2011 2012 2013

Myocardial Infarction (Heart Attack)
 Mean

Myocardial Infarction Composite
94%
95%
95%
96%
Linear (F.F. Thompson Hospital)

Includes aspirin upon arrival; aspirin prescribed at discharge; ACEI and ARB for LVSD;
beta blocker at discharge; lipid-lowering therapy at discharge.