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Clinical Enterprise FY2012 Institutional Quality Pillar Goals Final.

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Presentation on theme: "Clinical Enterprise FY2012 Institutional Quality Pillar Goals Final."— Presentation transcript:

1 Clinical Enterprise FY2012 Institutional Quality Pillar Goals Final

2 FY2012 Pillar Goals FY2012 GOAL FY2011 Baseline (Projected) FY2012 Threshold FY2012 Target FY2012 Reach Reduce O/E Mortality 0.76/0.73/0.71 (Target: 0.73) 0.73 (409 lives) 0.71 (440 lives) 0.69 (470 lives) Reduce Healthcare Acquired Infections 1.01 (recalibrated) 0.91 (- 57 infections) 0.86 (- 86 infections) 0.76 (- 145 infections) Reduce Adverse Events 8.08/7.67/7.27 (Below: 8.63) (recalibrated to FY12 convention: 1.42) 1.28 (new measurement convention) 1.20 (new measurement convention) 1.13 (new measurement convention) Achieve Top Performance in Clinical Programs 85%/90%/95% (Threshold: 88%) 88%90%95% Improve System Reliability 6-7/8-9/10-12 (Reach: 10) 6 – 78 – 910 – 12 2

3 FY2012 Pillar Goals Continued FY2012 GOAL FY2011 Baseline (Projected) FY2012 Threshold FY2012 Target FY2012 Reach Reduce Readmissions in AMI, HF, Pneumonia populations New Refine and Verify Baseline Develop or Adopt Predictive Models and Target Improvement Efforts Reduce Readmissions by 10% for each clinical condition Advance a Culture of Patient Safety, Improvement, and Reliability New Enlist and Prepare Three Pioneer Programs Initiate Two Projects per Program from Menu Increase Safety Climate Survey Response Rate to 65% in targeted programs (faculty, management, staff, residents, fellows, inclusive) 3

4 FY2012 Pillar Goals FY2012 GOAL Projected FY2011 Year-end SIR (Using FY12 Benchmarks) FY2012 Threshold FY2012 Target FY2012 Reach Overall Healthcare Associated Infections (- 64 infections) 0.86 (- 98 infections) 0.76 (- 152 infections) Central Line Blood Stream Infections (ICU) 0.76 (62 total infections) 0.68 (-6 infections) 0.65 (-9 infections) 0.57 (-15 infections) Central Line Blood Stream Infections (non-ICU) 1.16 (94 total infections) 0.99 (-13 infections) 0.87 (-23 infections) 0.75 (-33 infections) Catheter Associated Urinary Tract Infections (ICU) 0.96 (83 total infections) 0.86 (-8 infections) 0.82 (-12 infections) 0.72 (-15 infections) Surgical Site Infections 0.99 (279 total infections) 0.89 (-29 infections) 0.84 (-43 infections) 0.74 (-71 infections) Ventilator Associated Pneumonia 1.16 (69 total infections) 1.04 (-8 infections) 0.99 (-11 infections) 0.87 (-18 infections) 4 Threshold = 10% reduction; Target = 15% reduction; Reach = 25% Reduction** ** For non-ICU CLABSI: 15%/25%/35% reductions, respectively

5 FY2012 Pillar Goals: Hand Hygiene FY2012 GOAL FY2011 BaselineFY2012 Threshold FY2012 Target FY2012 Reach Hand Hygiene Compliance 88% (January - April 2011)88%92%95% 5

6 FY2012 Pillar Goals: Adverse Events FY2012 GOAL FY2011 BaselineFY2012 Threshold FY2012 Target FY2012 Reach Patients with pressure ulcers per 1000 Patient days 0.96 (155 patients) Falls with harm per 1000 patient days Overall Adverse Events goal is the sum of pressure ulcers and falls as defined above *Medication error moved to Strategic Issue Work Team for determination of data capture, measurement. Targeted improvements continue: anticoagulants, opiods, insulin, vancomycin

7 FY2012 Pillar Goals: Improve System Reliability FY2012 GOAL FY2011 BaselineFY2012 Threshold FY2012 Target FY2012 Reach Universal Protocol: Dissemination and spread of standardized UP/TO Target 1 Sustain UP/TO process in perioperative areas 2 Implement second timeout and debrief for intraoperative HO of complex cases in the perioperative environment 3 Implement UP/TO process in five high acuity, high risk procedural areas 7

8 FY2012 Pillar Goals: Improve System Reliability FY2012 GOAL FY2011 BaselineFY2012 Threshold FY2012 Target FY2012 Reach Blood Management: Developmental metrics RBC UtilizationTBD Q1 RBC WastageTBD Q1 Potential wrong blood in tube TBD Q1 8

9 FY2012 Pillar Goals: Advance a Culture of Patient Safety, Improvement, and Reliability FY2012 GOAL FY2011 BaselineFY2012 Threshold FY2012 Target FY2012 Reach Enlist 3 Pioneer Programs through internal Challenge RFP process New 90% Management and Program Leadership OR 40% Program FTE complete training 1-2 Focused Projects Implemented Programs achieve 65% response rate for Patient Safety Climate Survey 9

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