Vila Health: Mercy Hospital Safety and Quality Dashboard Legend M = Meets target C = Close to target D = Does not meet target Physical Therapy
Measure Purpose
Metric Target Jan Feb March
Operational Early Intervention. PT response to consult within 24 hours. 100% 91% C
79.5% D
96% C
Quality Percentage (%) of patients that meet 75% of their goals upon discharge.
100% 100% M
100% M
100% M
Endoscopy Measure Purpose
Metric Target Jan Feb March
Satisfaction Patient satisfaction with Endoscopy wait time (95% or greater rated good/excellent).
95% 95% M
92% C
88% D
Infection Control Measure Purpose
Metric Target Jan Feb March
Quality CAUTI Rate. <1.1 0.94% M
1.6% C
0% M
Safety % of clinicians who wash hands and use sanitizer appropriately. 98% 96% C
88% D
93% C
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Laboratory Measure Purpose
Metric Target Jan Feb March
Quality Critical lab values from RN to PHY within 20 minutes. 100% 76.6% D
58.5% D
76.6% D
Operational CB TAT ER-average minutes receipt to results. 92% 93.6% M
94.6% M
93.9% M
ICU/PCU Measure Purpose
Metric Target Jan Feb March
Safety All patients/families will receive discharge education that is documented in the medical record.
100% 100% M
100% M
100% M
Safety A current list of medications is provided to the patient at time of discharge.
100% 100% M
100% M
100% M
Safety Pt. fall rate/1,000 pt. days. <2% 1.4% M
1.7% M
3.3% D
Safety MRSA swab collection within 24. 100% 73.5% D
80% C
84.4% C
Emergency Room Measure Purpose
Metric Target Jan Feb March
Quality EKG for chest pain <10 mins of arrival. 100% 100% M
100% M
17% D
Quality Patients assessed for pain and appropriate interventions and reassessments are documented.
100% 85% D
48% D
76.00% D
Risk Management Report
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- Vila Health: Mercy Hospital Safety and Quality Dashboard