1. A Member of Daughters of Charity Health System Clinical Excellence Report Quality Patient Safety Committee June 16, 2015 Ashraf Gulzar, MSN, Director Quality Management Mike Thornton, BSN, Quality Supervisor Clinical Excellence Report Quality Patient Safety Committee June 16, 2015 Ashraf Gulzar, MSN, Director Quality Management Mike Thornton, BSN, Quality Supervisor

2. Framework for Clinical Excellence Measures that align national initiatives to the front line Heart Failure, Heart Attack, Pneumonia, Sepsis, VTE, Stroke, EED PSI 90 (QUEST Harm Index) 30-day all cause readmissions VBP Risk Adjusted Mortality Ratio Sepsis, Palliative Care VBP HCAHPS Overall Rating 9-10 Likelihood to Recommend VBP PFP $$ PFP=Partnership for Patients VBP = Value Based Purchasing $ = standalone payment penalty Length of Stay ALOS<GMLOS

3. O’Connor Clinical Performance: (FY15) May 2015 Attachment B.1 - Quality Report to QIC_May 2015.ppt Attachment B.1 - Quality Report to QIC_May 2015.ppt Attachment B.1 - Quality Report to QIC_May 2015.ppt Latest MonthYTD/MGoal Patient Experience (Top box 9/10) 63.4% (Apr)70.4% 76% Core Measures 95.9% (Mar)95.5% 96% Mortality 1.07 (Mar)0.92 0.85 Harm (Medicare Only) 0.43 (Mar)0.50 0.62 Readmissions (Medicare only) 1.25 (Feb)0.99 0.88 ALOS-GMLOS (Medicare Only) 0.05 (Apr)0.59 0.0