Performance Measures-OBGYN

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Primery Scsetelah gagal dalam proses lahir normal

Primery SC pada fetal disters
lahir normal setelah SC
Kegagalan melahirkan normal setelah SC
The delivery of an infant by planned repeat Cesarian Section weighing 2500 grams.
The delivery of an infant by planned repeat Induction of labor weighing 2500 grams.
Eclampsia
The in-hospital initiation of antibiotics 24hours or more after term vaginal delivery.
Excessive Maternal blood loss except with abruptio placenta/placenta previa as evidenced
by either a red cell transfusion, a hematocrit less than 22 or a hemoglobin less than 7
or a decrease in hematocrit of more than 11 or of hemoglobin more than 3.5
A Maternal length of stay more than 2 days after Vaginal Delivery
A Maternal length of stay more than 3 days after Cesarian Section
A Maternal readmission within 14 days of delivery
A Maternal death up to and including 42 days post partum.
Deaths of infants/fetus weighing 500 grams or more, sub-categorised by in-hospital
neonatal deaths, pre-partum stillborns and intr-partum stillborns.
The delviery of an infant weighing less than 1800 grmas in a hospital without a NICU
The transfer of a neonate to a NICU at another hospital.
An apgar score of 4 or less at 5 minutes in live born infants who weigh more than
1000 grams and less than 2500 grams.
The diagnosis of a massive aspiration syndrome
The diagnosis of a birth trauma (subdural and cerebral hemorrhage, fractures,
injuries to nerves, spinal cord, rupture of organs)
An infant weighing more than and equal to 2500 grams, having a clinically apparent seizure
prior to discharge from the delivery hospital, or apgar score of 4 at 5 minutes or requires
admission to the NICU for more than 24 hours

Performance Measures - Department of Medicine

1
2
3
4
5
6
7
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10
11

Mortality Review
Transfer to another acute facility
Use of Consultant for Chronic stable condition.
More than 3 Consultants
Failure to call Consultant when diagnosis is not known or patient is not responding.
Unplanned transfer to Special Care Unit
Code Blue Evaluation
No Code
Withdrawal of Life support
Neurological deficit not present on admission
Appropriateness of care for:
Chronic Heart Failure
Pneumonia
Urinary Tract Infection
Thrombolytic Therapy in patients with acute MI
12 Development of Pneumonia in patients treated in Special Care Unit
Development of Infections related to the use of intra-vascular devices in Special
Care Unit and Definitive Observation Unit.
13 Appropriateness of :
a. Colonoscopy
b. Upper Gastrointestinal Endoscopy
c. Endoscopic Retrograde Cholangiopancreatpgraphy
d. Bronchoscopy

Performance Measures- Department of Surgery

1 No Specimen (when specimen is expected)
2 Significant discrepancey between pre-op and pathological diagnosis
3 No gross and/or microscopic diagnosis when such is expected.
4 Fails approved medical necessity criteria for invasive procedure whether or not the
removal of a specimen was the intent of the procedure.
5 Cancellation of surgery after induction.
6 Unplanned hospital admission from outpatient surgery unit.
7 Transfer to another acute care facility
8 Operation for removal of foreign body left in operative site.
9 Wrong patient operated
10 Wrong side operated
11 Wrong procedure performed.
12 Unplanned removal or injury or repair to an organ or structure during surgery or
any invasive procedure.
13 Unplanned return to Operating Room on this admission.
14 Appropriatenss of Care for:
a. Colon
b. Breast
c. Lung Cancer
d. Peripheral Vascular Procedures
e. Fractured Hip
f. Total Joint Replacement
g. Laproscopic Cholecystectomy
h. Laser Surgery
16 No diagnosis established following surgery
17 Procedures that should be proctored/not proctored
18 No procedures for procedure performed
19 Operative consent incomplete, not on chart prior to surgery, procedure not same
as in consent, not signed, documented risks not explained
20 Unexpected transfer to Special Care Unit following procedure
21 Mortality Review
22 Complications during invasive procedure, ie: embolism, cardiac arrest, pneumothorax
infection, excessive bleeding.

23 Post-operative Wound Infection

24 Thrombo-embolism post-operative
25 Perforated Appendix
Performance Measures - Pediatrics
1 Any apgar score less than or equal to 4 at 5 minutes.
2 Battered/sexually abused child
3 Readmission for same condition within one year prior to this admission except
asthma, bronchitis, laryngotracheobronchitis or croup, diarrhoea.
4 Death
5 Transfusion
6 Non-specific diagnosis (ie: symptoms only) at discharge
7 Temperature 100 (oral) 101 (rectal) degrees farenheight within 24 hours prior discharge.
8 Febrile (ie: 103degrees Farenheight-oral) at leasst once daily for more than 96 hours
9 Hospital incurred adverse incident except parental carelessness/inattention
10 Transfer to another facility
11 Unusual Medical Diagnosis
12 Unplanned admission of an outpatient.

Medical Record Review

1 is the final diagnosis recorded on the face sheet in full, without use of
abbreviations/symbols.
2 Completion of a history and physical within 24 hours of admission.
3 Presence of current physical exam in patient's chart, prior to all surgery under
General or major regional anesthesia, except for emergency operations.
4 Recording of pre-operative diagnosis before surgery
5 Writing or dictation of operative reports immediately after surgery.
6 Presence of post-anaesthesia notes entered at a suitable interval after the
patients recovery from anaesthesia?
7 Dictation and signing of discharge summaries in patient's chart 14 days
post discharge.
8 Is there evidence of appropriate consents to treatment.
9 Is the medical record legible.
History/Physical
1 Does the H/P provide adequate documentation to assess the condition of the
patient to render the process of diagnosis and treatment?
a. On females, was the LMP noted and pelvic exam done?
b. Was the rectal exam done?
c. Are Medications, allergies and previous surgeries documented?
d. If diabetic, were fundoscopic exam and peripheral pulses documented?
2 Are therapeutic orders and ancillary tests appropriate to the disease/condition?
a. Were the orders concise, timed, dated and signed?
3 Were the appropriate consultations obtained?
a. If yes, is consultation complete?
4 Do progress nots adequately reflect the patient's course in hospital?
5 Are plans for follow up care and discharge instructions adequate?
6 Is final diagnosis consistent with clinical and test findings documented in the record?
7 Documentation in this medical record is:Adequate
Inadequate

Physician Reviewer:-

Date:

Yes

No

Performance Measures - Laboratory

Benchmark

1 Organizational performance Improvements

J
a
b

Quality Control problems are corrected within 24 hours

Timeliness of result reporting:
1 Results of all FBS to be ready within 2 hours
2 Reference lab results to be ready within 48 hours
3 All stat lab work reported within one hour from time
of lab receipt to time of phone report.
4 Panic values are double checked and called.
5 Proficiency testing and training for "point of care" lab

100%
100%
0%

11 Medication Use
a

Therapeutic drug evaluation draws coincide appropriately

with drug administration.

100%

111 Surveillance, Prevention and Control of Infections

a
b
1V

100%
100%

Management of Information
a

Gloves worn when drawing blood

Safety clothing worn while handling specimens

Laboratory requisitions completed properly

100%

Patients Rights
a

Patients confidentiality is maintained.

100%

Performance Measures - Pathology

1 Organizational Performance Improvements
a
b

c
d

Cases referred by pathologist for peer review

Appropriateness of specific lab tests
1 Blood Cultures
2 Stat Tests
Agreement with frozen section vs permanent section
Autopsy results agree with clinical findings.

95%
95%
100%
100%
100%

11 Care of Patient
a

Blood Bank Usage

1 Ordering
a) Total units of blood used
b) Cross Match
c) Indications for use
d) Patients receiving only one unit
e) Patients receiving over 5 units
2 Administration
a) Transfusion Reaction
b) Infusion time over 4 hours

111 Management of Information

a

Pathology reports for malignancy will include:

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5
6

Histologic analysis
Grade of tumour
Extension of tumour/margins/resection
Lymph node examined
Lymph node that contains evidence of metastatic disease
Primary tumour of breast, colon, lung will be cancer staged.

<2.5
100%
trend
trend
0%
100%

Performance Measures- Radiology Medical (Benchmarks 100%)

1 Improving Organizational Performance
a

Peer Review
1 Mammograms
2 Chests Xray in pediatrics
3 Lung Scans

Pneumothorax after invasive procedures

11 Assessment of Patients

Appropriateness of studies
1 Barium Enema -% of negative studies (benchmarks 10%)
2 HIDA scans - % of negative studies (benchmarks 10% )

Radiology Report Confirmation

1 Positive radiology report vs cholecystectomy
2 Estmated fetal age vs gestational age at birth
3 Presence/absence of leiomyomata post ultrasound report
4 Needle localization for abnormal breast tissue confirmed
by pathology
Appropriate use of non-ionic contrast

Performance Measures - Radiological Department

Benchmark

1 Organizational Performance Improvement

a

Canceled/Repeat procedure
1 Due to poor preparation
2 Technical error
3 Equipment failure

0%
0%
0%

Complications
1 Perforations
2 Hematomas
3 Infections(nosocomial)
4 Aspiration

0%
0%
0%
0%

Reject/repeat film rate analysis

10%

Mislabeled films and/or reports

0%

Timeliness of on-call Xray personnel

1 Answered beeper within 15 minutes
2 Into hospital within 30 minutes of being called

100%
100%

Outpatient Wating Time

1 Schedule 20 minutes
2 Unscheduled 30 minutes

100%
100%

MRI Scans meet technical standards:

1 Sequences are correct
2 Formatted images are diagnostic

100%
100%

Outpatient Questionairre (to be trended for improvements)

Performance Measures - Radiological Department (2)

11 Assessment of Patients
a
b
c

Patients are screened for allergies (ie: iodine, latex, medications)

Outpatients requiring contrast media not screened for HX
of CHF, Renal Failure.
Reaction to contrast media requiring intervention.

100%
0%
0%

111 Management of the Environment of Care

a
b
c
d

Film badges worn at all times

Environmental Safety Check
Radiation Physicist equipment check
Lead Apron check

100%
100%
100%
100%

1V Management of Information
a

Proper completion of Xray Request

1 Clinical Information filled out on request
2 Date of Examination
3 Exam requested matches reasson for Xray

100%
100%
100%

Performance Measures - Physiotherapy (Benchmarks of 100%)

1 Planning and Providing Care
a

Appropriateness of documentation
1 Initial Evaluation
2 Progress Report
a) Daily on inpatients
b) Every two weeks on Outpatients
3 Discharge Summary

Effectiveness of transfer gait training provided to patients.

Progress was noted in:
1 Level of need for assistance gradually reduced or eliminated.
2 Time (reduction in time) to move a distance
3 Distance travelled

Effectiveness of whirlpool TX to patients with cellulitis/wound

1
2
3
4

Evidence of debridement
Diminished swelling
Decreased pain level
Decreased wound size

11 Organizational Performance Improvement

a

Satisfaction
1 Patient
2 Physician

111 Management of the Environment of Care

Environmental rounds

Physiotherapy-Criteria for Documentation

1

Initial Evaluation
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a
b
c
d
e
f

Subjective Findings
Objective Findings
Short Term Goals
Long Term Goals
Prior level of functioning
Patient/Family Involvement

11 Progress Notes:
a
b
c
d
e
f
g

Completed daily (inpatient)

Complete every two weeks (outpatient)
Indicated treatment rendered
Frequency of treatment
Location
Any change in condition noted
Patient/family understanding of therapy

111 Discharge of Summary includes:

a
b
c
d

Goals met
Functional status upon discharge
Home Program
Mechanism for Follow-up

Physiotherapy-Environmental Rounds
a

Treatment Area
1 Treament area enclosed to guarantee privacy to patient
2 No modality equipment in cubicle other than equipment to be used
3 Clean linen for each patient

Electrical Safety
1 Use only equipment with three wire line cords; old equipment
properly grounded.
2 All electrical connection tight
Manual/auto adjustments in working order
3 Electrical equipment inspected every 6 months

Whirlpool
1 Disinfectant added to water in treatment of infected/open lesions
2 Turbine must be grounded
3 Whirlpool calibrated every quarter for temperature
4 Tank disinfected after each use

Hydrocollator
1 Unit grounded
2 Water clean hot (150 - 170 degrees farenheight)
3 Water covering packs at all times
4 Pack seams intact
5 Tongs used for pack removal
6 Unit water changed every q month, depending on usage

Paraffin Bath
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3

Unit well insulated

Thermostatic control
Should include a thermometer

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5

Sterilized q month
Covered at all times

Physiotherapy-Environmental Rounds
f

Ultrasound
1 Unit grounded
2 All switches off
3 Transducer and plug connections tight and clean

Electrical Stimulator
1 All wire and plug connections tight
2 Controls off before and after use
3 Electrodes in good condition

Transcutaneous Electrical Nerve Stimulator

1 Line Cord Units should be grounded
2 All electrodes washed and allowed to dry
3 Batteries recharged.

Intermittent Traction
1 Unit grounded
2 Dials at zero
3 Head halters, straps, cables, halter fastenings secure

Equipment Maintenance
1 Regular periodic equipment checks performed with documentation

Performance Measures-Food Services(1)

1 Nutritional Care
a

Evaluation of quality and appropraiteness of nutritional care

given to patients on tube feeding.
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1 Was current diet order evaluated for appropriateness?
2 If inadequate or not tolerated, was an alternate
recommendation made?
3 Was dietician's recommendation implemented by
physician?
4 Was recommendation implemented by physician?

Evaluation of quality and appropriateness of nutritional

care given to patients with decubitus ulcers:
1 Was current diet order evaluated for appropriateness?
2 If anadequate or not tolerated, was an alternate
recommendation made?
3 Was dietician's recommendation communicated to
physician?

Evaluation of Care Plans:

1
2
3
4

Was charting done within 72 hours of admission?

Were nutritional problems identified?
If problems identified, were there any plans for taking action?
Was action initiated to correct the nutritional problem?

Performance Measures-Food Services(2)

d

Evaluation of appropriatness of diet order to Diagnosis

1 Did diet provide adequate calories to meet the RDA?
2 Was adequate protein being provided?
3 Was the diet order in accord with the hospital approved
diet manual?
4 If not, did the dietician communicate alternative
recommendations to the physician?
5 Were the recommendations implemented by the physician?

11 Patient and Family Education

a

Potential food/drug interactions are identified and patient/family

informed of:
1 Potential adverse effects
2 Foods to avoid
3 Substitutional diet

Patient/family are educated on nutrition and substitution diet.

111 Organizational Performance Improvement

a

Evaluation of inpatient food service

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2
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4
5

Was the food taste acceptable?

Was the food presented neatly?
Was the food temperature satisfactory?
Was the food amount adequate?
Was the meal time schedule satisfactory?

Performance Measures - Pharmacy

1 Preparation and Dispensing
a

Dispensing Errors
1 Wrong Drug
2 Wrong Dosage
3 Wrong form of drugs
4 Error in labelling
5 Technician filling error

Outdated Drugs found on Units

Patient Profiles
1 Patient height and weight on profile
2 Patient age
3 Drug allergies are noted
4 Diagnosis on profile
5 No significant drug-drug or drug-food interactions noted.
6 No chemical or therapeutic duplications are found in current
drug therapy.
7 Drug or drug therapy regimen is the most const-effective
alternative.
8 No contra-indicated drugs administered

IV Mixture Preparation
1 Product is available at leasst 30 minutes before schedule
administrative time.
2 IV Labels contain:
Name/amount of drugs
Name of basic parenteral solution
Date/Time prepared
Expiration Time
Patient's name and location
Date/Time /Rate of administration
Supplemental Instructions
Initial of individual who prepared admixture
Cytotoxic drugs labeled differently
3 IV admixtures requiring refrigeration are stored properly.

Medication Use
1 Prescribing and Ordering
a

Antibiotic Review
1 Appropriateness
2 Prophylactic use
a) Initial dose not later than 1 hour prior to surgery
b) Final dose not less than 48 hours after surgery
3 Empiric Use
4 Use of restricted drugs
5 Initiation of antibiotic 24 hours post partum

Appropriate use and management of drugs

1
2
3
4

Thrombolytic agents
TPN
Pitocin
Emergency Department

Prescribing Patterns

2 Effects on Patients
a

Adverse drug reactions

Performance Measures - Infection Control

1 Surveillance, Prevention and Control of Infection

a
b
c

Availability of protective barrier as per standard precautions requirement.

Infectious waste handling and disposal
Nosocomial Infections:
1 Patients on ventilator who developed pneumonia
2 Post-operative pneumonia in patients experiencing:
i) Cholecystectomy
ii) Splenectomy
iii) Abdominal Bypass graft
iv) Abdominal perineal resection
v) Colon resection
3 Primary bloodsream infection in patients with:
i) Central line
ii) Umbilical line
4 Development of wound infections in "Clean" cases

11 Education
Pengukuran Kinerja - Pengendalian Infeksi
1 Surveillance, Pencegahan dan Pengendalian Infeksi
a
Ketersediaan penghalang pelindung sesuai kebutuhan tindakan pencegahan standar.
b
Penanganan limbah infeksius dan pembuangan
c
Infeksi Nosokomial:
1 Pasien pada ventilator yang mengembangkan pneumonia
2 pneumonia pasca operasi pada pasien yang mengalami:
i) Kolesistektomi
ii) Splenektomi
iii) perut Bypass graft
iv) perut reseksi perineal
v) Colon reseksi
3 Infeksi bloodsream primer pada pasien dengan:
i) Central line

ii) line umbilical

4 Pengembangan infeksi luka dalam kasus "Clean"

All clinical staff will have inservice in infection control/standard precaution.

Semua staf klinis akan memiliki intern dalam pengendalian infeksi / tindakan pencegahan standar.

Quarterly Evaluation of Standard Precautions/Body Substance Isolation

Date:
Methodology:
Findings:
Reviewer:

Concurrent study of Healthcare Workers

A total of
observations made in the

department
Yes

Gloves worn when drawing blood

Gloves worn when handling blood and body fluids

Gloves changed btween patients?

Hands washed after gloves removed?

Masks, goggles, gowns readily available?

Does employee know location of Equipment?

No

Non-compliant

Masks, goggles worn if splattering possible?

Used needles not recapped and disposed of in proper containers

Areas properly cleaned following contamination with body fluid?

Evaluasi Triwulan Standar Bahan Kewaspadaan / Tubuh Isolasi

Tanggal :
Metodologi: Studi Concurrent Pekerja Kesehatan
Temuan: Sebanyak pengamatan yang dilakukan di departemen
resensi buku:

1 Sarung tangan dipakai saat menggambar darah

2 Sarung tangan dipakai saat menangani darah dan cairan tubuh
3 Sarung tangan berubah btween pasien?
4 Tangan dicuci setelah sarung tangan dilepas?
5 Masker, kacamata, gaun tersedia?
6 Apakah karyawan mengetahui lokasi Equipment?
7 Masker, kacamata yang dikenakan jika muncrat mungkin?
8 Jarum bekas tidak recapped dan dibuang dalam wadah yang tepat
9 Area benar dibersihkan kontaminasi berikut dengan cairan tubuh?
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Performance Measures - Business Office

1 Organisation Performance Improvement
J
a
b
c
d

Customer Complaints
Errors in Patient Bills
Error in Insurance/Corporate claims
Turn around time for patient discharge to billing over 30 days

Performance Measures - Materials Management

2 Organisation Performance Improvement
a
b
c
d

Supplies are available for filling departmental orders

Number of vendors for similar supplies are minimize for cost control
Special supply request are filled within time frame requested
Old/outdated supplies in Store

0%
0%
0%
0%

Risks Management Monthly Safety Committee Report

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1

a
b
c
d
e
f
g
h
i
j
k
l

Patient Injury
Employee Injury
Visitor Injury
Needle Stick Injury
Security Elopement
Fall Attended
Equipment Failure or Malfunction
Equipment User or Malfunction
Equipment User Error
Utility Failure or Malfunction
Utility User Error
Medical Device Recalls

No of Admissions
Average Daily Census
No of Discharges
Cedera pasien
Cedera karyawan
Cedera pengunjung
Needle Tongkat Cedera
keamanan Elopement
jatuh Menghadiri
Kegagalan peralatan atau Kerusakan
Peralatan Pengguna atau Kerusakan
Kesalahan Peralatan Pengguna
Kegagalan utilitas atau Kerusakan
Kesalahan utilitas Pengguna
Alat Kesehatan Penarikan
idak ada Penerimaan
Rata-rata Harian Sensus
Tidak ada dari Pembuangan

11 Environment of Care
a
b
c

Incidents of needlestick Injury shall decrease by

quarterly
Employee back injuries shall decreasse by
All employees are inserviced annually on:
1) Fire Safety
2) Hazardous Materials
3) Hazard detection Survey
4) Illness and Injury Protection Program
5) Exposure Control Program
6) Emergency Preparedness Program
7) Security Program

%
% quarterly

nsiden Cedera jarum akan menurun%

triwulanan
Cedera punggung Karyawan harus decreasse oleh% triwulanan
Semua karyawan inserviced setiap tahunnya pada:
1) Fire Safety
2) Bahan Berbahaya
3) deteksi bahaya Survey
4) Penyakit dan Program Perlindungan Cedera
5) Program Pengendalian Eksposur
6) Program Kesiapsiagaan Darurat
7) Program Keamanan

Performance Measures - Engineering Department

1 Environment of Care
a

Patient/Employee Safety

Benchmarks of 100%

F
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)

Disaster Drills
Fire Drills
Emergency Generator Procedure
Policies/Procedures current
Preventive Maintenance Procedures (within 30 days current)
Department Inservice monthly
Fire Sprinkler Valves (open except during service)
Bio-med equipment Checks(current to month due date)
Round Checks (perform Monday to Friday)
Work Order Response (response initiated within 48 hours)
Equipment Inventory (current within 6 months)
CPR
Patients rights and confidentiality
Orientation Program

Performance Measures - Environmental

1 Organisaitonal Performance Improvement

a
b
c

Satisfaction Questionnaire
Patients Complaints
Staff Complaints

11 Environment of Care
a

All environmental service staff will complete annual Inserviceon Infection Control and Safety.

Housekeeping Inspections

Organizational Performance Improvement Board Report

Performance Measures
1 Volume
a Number of Inpatient discharges
1 Total number if discharges
Average length of stay (OLOS)
2 Total number of Corporate discharges
Average length of stay (OLOS)
3 Total number of Insurance discharges
Average length of stay (OLOS)
b
c
d

No day/outpatient surgeries
No of Emergency visits
% Occupancy

11 Mortality
a Total number of deaths
1 % of deaths
b Perioperative mortality rate (deaths within 48 hours
of surgery or invasive procedure)
c Newborn Mortality Rate
d Maternal Mortality Rate
e No of patient deaths in Emergency Department
f % of deaths meeting criteria or expected justified
mortality.
g Number of autopsies performed.
111 Hospital Acquired Infection
a Total Rate
b Clean surgical rate
c Post partum infection rate
d Neonatal Infection Rate

Benchmarks

Comments

QTR 1

QTR 2

QTR 3

1V

Risk Management
a No of claims involving patient injury/death
b No of claims involving hospital risk/loss
c No of Medication Errors
d No of patient/visitor falls

Case Management
a Denial rate for private insured patients
b Appeal success rate
c Denial rate for Corporate patients
d Appeal success rate

V1

Medication Use
a No of drug reactions resulting in prolonged
length of stay.
b No of drug reactions resulting in temporary or
permanent patient injury and potential hospital
liability.
c No of cases reviewed not meeting established
criteria.

V11

Blood Usage
a No of transfusion reactions resulting in prolonged
length of stay.
b
% of cases reviewed not meeting established criteria
c Crossmatch/transfusion ratio
d No of wasted units

V111 Surgery/Invassive Procedures

a Unplanned returns for surgery
b No of Complications
c No of tissue cases reviewed
d No of meeting criteria
e No of non-tissue cases
f No of meeting criteria

1X

Cesarean Sections
a % of meeting criteria
b % of repeat procedures
c % of primary procedures
d % of Vaginal deliveries secondary to C-section
deliveries (VBAC)

Codes
a % of successful codes performed in:
1 Emergency Department
2 SCU
3 Medical/Surgical
4 Pediatrics
5 OB

X1

Transfer to another acute care facility

a No of emergency patients transferred
b No of inpatients transferred for services not
provided by the hospital
c % of transfers meeting transfer criteria.

X11

Special Care Unit

a No of transfer from lower level of care in hospital to special
care unit.
b No of patients admitted to special care units not
meeting admission or discharge criteria.
c No of patients returned to special care unit within
48 hours of discharge from unit.
d No of patients that die within 48 hours of discharge
from unit.

X111 Readmissions
a No of readmissions within 30 days from related or
similar diagnosis/treatment.
b % of cases meeting criteria for appropriateness
of first discharge and of readmission

X1V AMAs
a No of Emergency patients leaving AMA
b No of other patients leaving AMA
XV

Patient Complaints
a No of patient/family complaints involving patient
care
b No of patient/family complaints involving billing errors
or charges for services
c No of patient/family complaints involving a hospital
provided service or employee
d
% of unresolved complaints

QTR 4

Performance Measures - Emergency Department

1 Assessment
a General Documentation/Triange
11 Care of the Patient
a Standard of Care:
1 Head Injury
2 Poisoning/Overdose
3 Abdominal pain-non-traumatic
4 Shortness of breath
5 Fractures/Dislocations/Sprains
6 Eye Complaints
7 Trauma
8 Vaginal Bleeding
9 Laceration
10 Seizure
11 Chest pain
12 Pediatrics
13 Pediatric Fever
b

Medication Use
1 Medication Error

111 Continuum of Care

a Infection Control of Unit
b Standard Precaution
1V Organizational Performance Improvements
a
b
c
d
e

Patient/physician complaints
AMA
LWBS
Elopement
Patient Satisfaction Survey

100%

100%

0%

Performance Assessment/Measures
1 Assessment
Yes
a
b
c
d
e

Admitting Date (including Vital signs, actual weight, height etc)

Orientation to Unit
Medication taken at home
Allergies
Special Needs

System Review-both subjective and objective

a
b
c
d
e
f
g

Gastrointestinal
Cardiovascular
Respiratory
Neurological/Endocrine
Musculoskeletal
Mental Status
Discharge Planning

2 Plan of Care
a
b
c
d

Plan implemented on date of admission

Plan individualized on date of admission
Each problem (nursing diagnosis) has outcome with deadline
Plan is updated timely evidenced by:
1 Discontinuance of problems solved
2 New problems initiated with date
3 Outcome
Charting on Nurses notes are directly related to problems in
plan of care at least once in 24 hours.

Nursing Performance Assessment (2)

3 Medication
a
b
c
d

Are the reasons for PRN medications recorded?

Has the effect of PRN medication been charted?
Meds are charted with the appropriate time, route dose and site of injection
MAR contains initials, full signatures, and title of administering nurse.

No

N/A

Comments

Are "omitted" or "refused" medications charted properly on the medication

record and in the nurses notes?

4 Intake/Output
a
b

Intake/Output were recorded each shift

Totaled each 24 hours.

5 Documentation of IV Care
a
b
c
d
e

Reflects site checked each shift

Signs of infiltration/phlebitits documented with follow-up
Site/size and type of needle used to start IV Chart
IV Tubing related
IV Dressing site is dated, timed and initialed.

6 Patient Education
a
b

Patient education during hospitalization is apparent

Patient education is specific to care plan problems

7 Transfer
a
b

Transfer note completed by transferring unit

Admission transfer note completed by admitting unit.

Nursing Performance Assessment(3)

8 Legibility/Legality
a
b

c
d

e
f

Is nursing record legible?

Are orders noted with:
1 Time
2 Date
3 Signature of rsponsible RN
Were unused portions of record (nursing) crossed out?
A signature completes:1 Each nursing notation
2 Ends each nursing page
Where initials are used, is there a signature to validate same?
Only correct abbreviations are used?

9 Environmental

a
b
c
d

Room appearance is neat and orderly; odor free

Lighting, temperature and ventilation satisfactory to patients.
Urinal and bedpan empty, rinsed and stored properly.
Soiled linen and contaminated waste are put directly into appropriate
containers, not on bed or chair.

10 Welfare and Safety

a
b
c
d
e
f
g

Patient has correct and legible armband

Bed is in low position with wheels locked
Side rails are in inte correct position for patient.
Equipment etc is functioning properly
Call light is within easy reach of patient
Drainage tubes are patent and properly connected
Dressings are dry and intact

Nursing Performance Assessment (4)

11 Hallway and Nursing Station
a
b
c
d
e

Hallways are clear or necessary equipment in on one side only

Nursing station is clean and unlcuttered
Crash cart is checked each shift
Food refrigerator temperature checked every shift
1 all food covered and dated
Medication refrigerator temperature checked every shift.

12 Medication Carts
a
b
c
d

All medications cart locked

Narcotics double locked
Multidose vials labeled with date opened and intitialed
Multidose vials discarded after 30 days

13 IV Therapy
a
b

IV bag is labeled correctly

Tubing is:
1 Dated
2 Changed every 72 hours (regular IV)
3 Changed every 24 hours (hyperal)
Site is clean and without evidence of infiltration.

14 Oral Hygeine of Incapacitated Patients

a
b
c
d
e
f

There is evidence of daily cleaning of teeth/dentures

Is patient on high dose and/or multiple antibiotics?
If so, evidence of thrush?
Doctor notified of possible fungal infection?
Lips and tongue cleaned and mosturised
Dentures are stored in containers labeled with patient's name and room number

Nursing Performance Assessment (5)

15 Foley Catheter Care
a
b
c

d
e
f

Foley's catheter secured to patient's thigh

Is the catheter tubing straight and free of kinks or coiling
Is the straight drainage bag:
1 off the floor
2 Clean/free of odor
3 Placed at the right side of the bed patient is facing when turned
4 Below the level of the patient bladder
Is the catheter in good condition, free of tape or musous buildup
Is urine flowing well through the tubing? Downward direction?
Is reason for the Foley's catheter documented?

16 Patient Education
a

Can patient verbalize understanding of:

1
2
3
4
5
6
7

Pending procedures?
Needed specimen collection?
Disease process?
Nursing Care being delivered?
Discharge/needs planning?
Does patient verbalize understanding of pre-operative care?
Does patient verbalize understanding of OT and recovery room care?
a) Anesthesia
b) Frequent vital signs
8 Does patient verbalize unerstanding of post-operative care?
a) Turn, cough, deep breath?
b) Tubes/equipment to expect?
c) NPO status and diet advancement?
d) Availability of pain medication?
e) Importance of expressing feelings?

Performance Measures- Critical Care Unit

1 Assessment of Patients
a

Availability of Physician
J
1 New Cardiac patients seen within 4 hours
2 All other new admits seen within 6 hours
3 Physician responds to Emergency call within 30 minutes

Return to the Special Care Unit within 48 hours of transfer to a

lower level of care

11 Care of the Patient

a

Standards of Care
1
2
3
4
5
6
7
8
9
10
11

Pressure Monitoring
Ventilator Patient Care
Temporary Pacer
MI/RO MI
COPD
CHF
Shock
Pain Management
Thrombolytic Therapy
Skin Integrity
Hemodialysis

IV Therapy

Foleys Catheter Care

Oral Hygeine of Incapacitated patients

Medication Use: medication errors

Appropriate Use of Restraints

111 Patient/Family Education

1V

Environment of Care
a

Patient Environment

Welfare and Safety

Hallway and Nurses Station

d
V1

Medication Carts

Information Management
a

Documentation
1
2
3
4
5
6
7
8

Assessment
Plan of Care
Medication
Intake/Output
Documentation of IV Care
Patient Education
Transfer
Legibility/Legality

Operating Room-Infection Control Criteria

1 Indicator: Integrity of sterile field is maintained.
Met
Not Met
a
Surgical hand scrub performed according to policy and procedure.
b
Proper gowning and gloving technique used.
c
Sterile drapes placed on all tables used for equipment and intruments.
d
Tables are clean and dry prior to use
e
In draping, material held compact and above waist level and draping
done from operative site to periphery.
f
While placing drapes, gloved hands protected by cuffing draping
material over hands.
g
Drapes are not moved or shifted once placed
h
before handling a sterile item, the unscrubbed person checks the
package integrity, chemical process indicator and expiry date.
i
All items introduce to the sterile field are dispensed by methods
which maintain sterility of the item and integrity of the sterile field.
j
When dispensing solutions:
1. entire content of bottle are poured or the remainder is discarded
2. Solution receptacle is near the edge of the table.
3. Solution poured without splashing onto the sterile field.
k
Sterile field is prepared as close as possible to scheduled time of
use and not covered.
l
Conversations in the OT kept to a mininmum
m
All cables, tubing etc are secured to the sterile field with non-perforating
devices.
n
Scrubbed person's arms and hands are kept within the parameters
of the sterile field at all times.
o
Scrubbed team members change position by moving face to face
or back to back
p
Scrubbed persons remain close to the sterile field
q
Scrubbed persons avoid changing levels and are seated only when
entire procedure will be performed at that level.
r
Unscrubbed team members move from unsterile to unsterile areas
while keeping adequate distance from the sterile field.
s
Unscrubbed persons approach while facing the sterile field and do
not walk between two sterile fields.
Proper preparation of Instrument Tray
Indicator:
All instrument trays shall be assembled, packaged, sterilized and stored according to standards
a
Stored in proper area
b
Item is properly labelled.
c
Lebel is legible
d
Contains the following:
Expiration dates (if applicable)
Sterilization date
Load number
Sterilizer number
e
Item is wrapped/packaged properly
f
Tray contains proper quantity and type of supply items/instruments
g
Tray is initialed by person who prepared it.
h
Tray contains "count" sheet
i
All tray contents are clean and usable
j
Tray includes a chemical indicator
k
If the outer wrap is muslin, is it:
serviceable?
Double wrapped?
Worn too thin to be usable?

Maintenance of Blood/Fluid Precautions in OT

Indicator:

Standard Precautions observed and maintained

Gloves are worn whnever contact with blood and body fluids is anticipated.
Gloves are worn when moving patients postoperatively
Gloves are worn when touching mucous membranes or open skin
Hands are washed between patient contacts
Hands are washed after accidental contact with blood/body fluids and/or
after gloves are removed.
f
Masks and protective eye wear provided/worn whenever aerosolization
or splattering or blood/body fluids is anticipated (extubation, laryngoscopy etc)
g
Masks and protective eye wear provided/worn for all scrubbed personnel
h
Sharp objects (needles/blades) are handled in such a manner as to prevent
accidental cuts/punctures
i
Blood spills are cleaned immediately with appropriate disinfectant.
j
All reusable items are appropriately sterilized.
k
Used needles are not broken/recapped, but are discarded in puncture
resistant containers.
l
Use of appropriately labelled infectious waste/linen containers.
Patient Experiences no Tissue Damage or Compromised Circulation.
Indicator:
Pre-operative assessment and documentation of patient's physical status is completed.
a
Condition of skin noted
b
Existence of abnormalities, injuries, sensory impairment noted/documented.
c
Previous surgery.existence of metal implants noted/documented
d
Cast inspected for adequate padding/protection
e
Appropriate/adequate padding/positioning aids used
f
Patient offered warm blanket, repositioned etc
g
Hypothermia unit used according to manufacturers recommendations.
Psychological Aspects of Care to Patients in the OT
Indicator:
Quality and appropriateness of Psychological support to patients in the OT
a
Assessment of Psychological aspects
b
Patient encouraged to ventilate concerns and fears
c
Questions answered regarding nursing matters
d
Questions on Medical Care referred to Physician
e
Room preparations completed prior to patient entry
f
Noise/traffic minimize
g
Patient orientated to operating room as needed
h
Clear and concise explanations given
i
Patient's emotional status communicated to other appropriate team members
j
Patient remained with during induction
k
A caring and supportive attitude conveyed to patient
l
Spotlight kept off of patient until asleep
m
Dentures/glasses/hearing aid removed in OT
n
Patient protected from self inflicted injury
o
If local, remained with/reassured patient during procedure
p
Vital signs taken during procedure
q
Patient saw surgeon prior to induction
Operating Theatre
Patient is free from Injury Related to Positioning
Indicator:
Appropriateness of positioning of patients in OT
a
Position is proper for procedure
b
Sufficient help is used for safety of patient
c
Sufficient padding and support used to support body parts per policy/procedure
d
Proper body alignment is maintained
a
b
c
d
e

e
If turned, done on signal by anesthesiologist
f
Head turned gently and supported
Patient is free from Injury Related to Positioning(contd)
Indicator:
Appropriateness of positioning of patients in OT
g
Ears and eyes protected
h
Pressure prevented on chest including during procedure
i
Arms placed on armboards, pronate palms, pressure on elbows prevented.
j
Safety strap in place
k
Pressure points checked/padded
l
No redness, bruises, evidence of injury or pressure areass noted on D/C form OT
m
No problems with circulation due to positioning noted
n
Position/change in position documented
Patient is free from injury Related to transfer from the OT table to the stretcher
Indicator:
Adequacy of lifting and moving patients in OT
a
Adequate personnel are secured for help
b
All body parts are supported during move
c
Patient moved with unison with directions
d
Proper body mechanics used by all personnel
e
Consideration given to the patient's condition
f
Patient is made comfortable following move
g
Safety strap/side rails etc, utilize
h
There is no complaint from the patient regarding move
i
There is no injury/complaint of the personnel
j
IV and all other equipment protected during move
k
IV and all equipment remain intact following the move.
Maintenance of Fluid/Electrolyte Balance
Indicator:
Fluid/Electrolyte balance will be maintained
a
Intake monitored and documented
b
Output monitored and documented
c
Evidence of post-operative bleeding monitored/documented
d
Pre-operative results checked
e
Abnormal laboratory values communicated to appropriate team members
f
Blood available as ordered
g
Blood replacement initiated as ordered
h
Post-operative nausea/emesis noted/documented
Patient is free from Inury Related to Electrical Hazards
Indicator:
The Electro-surgical Unit (ESU) shall be used following all safety guidelines in the OT
a
ESU inspected by bio-medical within six months
b
ESU clean and protected from spills
c
ESU not used in presence of flammable agents
d
Plug, cord and connections inspected before use
e
Cord reaches outlet without stress
f
ESU safety features tested before use
g
Power setting set as low as possible
h
Patient's skin evaluated before and after use;especially uner ground pad,
EKG leads, pressure points
i
Ground pad/cord inspected for damage before use
j
Ground pad cord is long and flexible to reach without stress on any connection
k
Pad placed on clean, dry skin, over large muscle mass as close to operative
site as possible avoiding bony, hairy and scarred areass.
l
Pad maintains uniform body contact
m
Pencil cord fastens in correct receptacle
n
Pencil and cord free of loops/twists; no contact with metal clamps
o
During procedure, pencil placed in clean, dry, non-conductive, highly
visible area
p
ESU pencil tip is kept free of charred tissue during procedure

Documentation includes:Generator ID number, Ground pad placement/location,

EKG pads placement/location, Patient's skin condition before and after use.

Trending Sheet
Key Function/Performance Measures
1 Management of Information
a. Documentation
1 Pre-op checklist complete and RN signature
2 Laboratory/EKG results on chart
3 H & P on chart
4 If no H & P, evidence of H/P dictated
5 Consent for procedure completed and signed
6 If Hysterectomy, special Hysterectomy consent on chart.
7 Sterilization permit on chart if applicable
8 Informed consent documented on progress notes
9 Indications for surgery documented by physicians in
charge in progess notes if patient is unable to sign
and there is no guardian.
10 ID band on patient
11 Informed consent for blood if indicated
12 Informed consent for Breast Cancer treatment (if indicated)
11 Surveillance, Prevention and Control of Infections
1 Integrity of sterile field is maintained
2 All instrument trays shall be assembled, packed,
sterilized and stored according to standard.
3 Standard precautions observed/maintained in OT
111 Assessment
1 Pre-operative assessment and documentation of
patient's physical status is completed.
1V Care of Patient
1 Quality and appropriateness of psychological support
to patients in the operating room.
2 Appropriateness of positioning of patients in OT
3 Adequacy of lifting and moving patients in OT
4 Fluid and electrolyte balance is maintained.
V
Management of the Environment of Care
1 ESU (Electrical Surgical Unit) shall be used following
all safety guidelines in OT
V1 Organisational Performance Improvement
1 Intraoperative readiness of Operating room staff

Benchmark

J
100%
100%
100%
100%
100%
100%
100%
100%
100%

100%
100%
100%
100%
100%
100%

100%

100%
100%
100%
100%

100%