Clinical EnterpriseFY2012 Institutional Quality Pillar Goals

Final

FY2012 Pillar Goals

FY2012 GOALFY2011 Baseline

(Projected)

FY2012Threshold

FY2012Target

FY2012Reach

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 Events8.08/7.67/7.27(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 – 7 8 – 9 10 – 12

2

FY2012 Pillar Goals Continued

FY2012 GOALFY2011 Baseline

(Projected)

FY2012Threshold

FY2012Target

FY2012Reach

Reduce Readmissions inAMI, 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

NewEnlist 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

FY2012 Pillar Goals

FY2012 GOALProjected FY2011

Year-end SIR(Using FY12 Benchmarks)

FY2012Threshold

FY2012Target

FY2012Reach

Overall Healthcare Associated Infections 1.01 0.91

(- 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

FY2012 Pillar Goals: Hand Hygiene

FY2012 GOALFY2011 Baseline FY2012

ThresholdFY2012 Target

FY2012 Reach

Hand Hygiene Compliance 88% (January - April 2011) 88% 92% 95%

5

FY2012 Pillar Goals: Adverse Events

FY2012 GOALFY2011 Baseline FY2012

ThresholdFY2012 Target

FY2012 Reach

Patients with pressure ulcers per 1000 Patient days

0.96(155 patients) 0.88 0.83 0.78

Falls with harm per 1000 patient days 0.46 0.40 0.37 0.35

Overall Adverse Events goal is the sum of pressure ulcers and falls as defined above

1.28 1.20 1.13

6

*Medication error moved to Strategic Issue Work Team for determination of data capture, measurement.Targeted improvements continue: anticoagulants, opiods, insulin, vancomycin

FY2012 Pillar Goals: Improve System Reliability

FY2012 GOALFY2011 Baseline FY2012

ThresholdFY2012 Target

FY2012 Reach

Universal Protocol: Dissemination and

spread of standardized UP/TO

Target

1Sustain UP/TO

process in perioperative

areas

2Implement

second timeout and debrief for

intraoperative HO of complex

cases in the perioperative environment

3Implement

UP/TO process in five

high acuity, high risk

procedural areas

7

FY2012 Pillar Goals: Improve System Reliability

FY2012 GOALFY2011 Baseline FY2012

ThresholdFY2012 Target

FY2012 Reach

Blood Management: Developmentalmetrics 3 4-6 7-9

RBC Utilization TBD Q1

RBC Wastage TBD Q1

Potential wrong blood in tube TBD Q1

8

FY2012 Pillar Goals: Advance a Culture of Patient Safety,

Improvement, and ReliabilityFY2012 GOAL

FY2011 Baseline FY2012 Threshold

FY2012 Target

FY2012 Reach

Enlist 3 Pioneer Programs through internal Challenge

RFP processNew

90% Management and Program Leadership

OR40% Program FTE complete training

1-2 Focused Projects

Implemented

Programs achieve 65%

response rate for Patient

Safety Climate Survey

9

Healthcare Associated Infections

Healthcare Acquired Conditions

Compliance & Regula-tion

QPS Education & Skill

Development

Data Integrity & Reporting

System Support to VUMC Quality

Structures

Event Analysis & Risk Mitigation

Clinical Care Performance & Strategic Issue Studies

Quality & Patient Safety Cores to Support Pillar Goalsand Advance Culture of Excellence