QUALITY AND PATIENT SAFETY COMMITTEE AGENDA · 2012-04-17 · QUALITY AND PATIENT SAFETY COMMITTEE...

QUALITY AND PATIENT SAFETY COMMITTEE AGENDA

April 10, 2012

The Quality and Patient Safety Committee of the Board of Directors of the Cook County Health and Hospitals System will meet on Tuesday, April 17, 2012 at the hour of 12:00 P.M. at 1900 W. Polk Street, in the Second Floor Conference Room, Chicago, Illinois, to consider the following:

Time/Presenter (times are approximate)

I. Attendance/Call to Order 12:00/Chairman Ansell

II. Public Speakers 12:00-12:10

III. Report from System Chief Medical Officer 12:10-12:15/Dr. T. Mason

IV. Report from System Interim Chief Nursing Officer 12:15-12:20/T. Russell

V. Report from System Director of Quality and Patient Safety B. Farrell

A. Quality report from the Ambulatory and Community Health Network 12:20-1:00/Dr. S. Stabile, of Cook County I. Marks, Dr. J. Neafsey and Dr. E. Martinez

VI. Recommendations, Discussion/Information Item

A. Reports from the Medical Staff Executive Committees 1:00-1:10

i. Provident Hospital of Cook County Dr. P. Wakim ii. John H. Stroger, Jr. Hospital of Cook County Dr. D. Goldberg

VII. Action Items

A. Minutes of the Quality and Patient Safety Committee Meeting, 1:10-1:15/Chairman Ansell March 20, 2012 B. Proposed Academic Affiliation Agreements (Renewals and New Agreements) 1:15-1:30/Dr. J. O’Brien C. Any items listed under Sections VI, VII and VIII

AGENDA Tuesday, April 17, 2012 Meeting of the

Quality and Patient Safety Committee

VIII. Closed Session Item 1:30-1:35

A. Medical Staff Appointments/Re-appointments/Changes C. Luchsinger Closed Session

Motion to recess the regular meeting and convene into closed session, pursuant to the following exceptions to the Open Meetings Act: 5 ILCS 120/2(c)(17), regarding “the recruitment, credentialing, discipline or formal peer review of physicians or other health care professionals for a hospital, or other institution providing medical care, that is operated by the public body,” and 5 ILCS 120/2(c)(11), regarding “litigation, when an action against, affecting or on behalf of the particular body has been filed and is pending before a court or administrative tribunal, or when the public body finds that an action is probable or imminent, in which case the basis for the finding shall be recorded and entered into the minutes of the closed meeting.”

IX. Adjourn Committee Members: Chairman: Ansell Members: Board Chairman Batts (Ex-Officio) and Directors Butler and Muñoz

Affiliation Agreements for the QPS Committee Meeting April 17, 2012

No. Specialty New/Renewal Partner Reason Dollars/yr # of Res/Yr

1Pulmonary New UIC Agreement formerly between UIC and the

city. CCDPH now running the TB clinics. $0 0.5 FTE fellows

2

Pulmonary New McGaw Agreement formerly between UIC and the city. CCDPH now running the TB clinics.

$0

Variable-attend the clinic ½ day/wk

3Psychiatry New Rush

Allow the Rush residents to gain experience with mental illness in incarcerated patients at Cermak $0

Up to 2.0 FTE

4Adolescent Medicine New UIC Joint Fellowship -Allows adolescent fellows

to rotate at both hospitals/clinics $0 1.0 FTE Fellow

5Radiation Oncology New LUMC Provide Radiation Therapy experience for

LUMC $0 0.4 FTE

6Emergency Medicine New McGaw Provide EM experience for OB/Gyne

residents $0 1.0 FTE

7Surgery Critical Care New McGaw Provide SICU experience for OB/Gyne


8 Orthopedics New McGaw Amend current agreement to allow PGY1’s to rotate here $0 1.0 FTE PGY1

9Allergy/Immunology New Jackson Park Provide A/I experience for Jackson Park


10 Oral Surgery New Resurrection Provide our Oral Surgery residents Orthognathic cases when they arise $0 Variable

11 Podiatry New Weiss OFH is now a ROC, so interns to rotate at JSH $0 Variable

12 Pediatrics New Alivio Allows one Pediatric Resident to work in high volume clinic $0 0.1 FTE

13 Neurosurgery Renewal Rush Provide care for our neurosurgical patients $74,446 1.0 FTE

14 Neurosurgery Renewal McGaw Provide care for our neurosurgical patients $75,000 1.0 FTE

15 Nephrology Renewal UIC Provide care for our patients with renal failure $156,915

2.0 FTE Fellows

1 of 3 Reviewed by the Work Group on Affiliations on 3/29/12


16 General Surgery Renewal UIC

2 Surgery residents from UIC provide clinical coverage on the Colon and Rectal Surgery service $150,379

2.0 FTE Residents

17 ENT Renewal UIC Provide ENT care for our patients (we don’t have our own ENT residents) $229,002 3

18

Surg/Pathology Renewal UIC Provides support to our pathologists (we don’t have our own pathology residents) $330,323 4.0 FTE PGY7

19

Urology Renewal ChristResidents provided experience in brachytherapy, infertility, robotic surgery, and pediatric urology

Christ reimbursesJSH salary and benefits

Up to 1.0

20

Neurosurgery New Northshore University

Allow our resident experience in spine cases NSU reimburses JSH

salary and benefitsUp to1.0 FTE

21

Family Medicine

Renewal of CEMA and Program Addendum

Loyola University Medical Center

Joint Residency –Residents provide:Approx 19,422 Clinic visits/yr; 500 deliveries/yr, and participate with approx. 1700 inpatient admissions annually $2,237,000

32.5 FTE Residents, 1.5 Faculty, support staff

22

Master Agreement Renewal UIC Allows the creation of Program Addenda

$0 N/A

23 Pulmonary Renewal Black Lung Clinic

Provide Fellows experience in early treatment of Black Lung Ds $0 N/A

24 Neonatology Renewal Christ Provide Training for Congenital Heart disease in newborn $0

2 fell. spend 4 wks each

25 Pain Renewal National

University

Provides instruction in acupuncture to our pain fellows and clinical experience for acupuncture interns $0

N/A

26

General Surgery and Plastic Surgery

Renewal UIC Residents rotate on Burn service to get experience not available at UIC $0

1.0 Gen Surg FTE + 0.66 Plastic Fellow

27

Surgery Critical Care Renewal Advocate Allows our SCC fellows to experience

critical care from a remote site $0 1-3 fell. spend 40 hours each



28Toxicology Renewal UIC Joint Fellowship – allows fellows to rotate

at UIC and JSH $0

Variable (4.0 fellows in the program)

29 Toxicology Renewal Northshore University

Allows our Tox fellows to get community experience $0 Variable

30 Pediatrics Renewal Esperanza Allows one Pediatric Resident to work in high volume clinic $0 0.1 FTE

31 Endocrinology Renewal Jackson Park Allows JP FM residents endocrine experience $0 1.0 FTE


John H. Stroger, Jr. Hospital of Cook County

Medical Staff Appointments/Reappointments and Non-Medical Staff Action Items Subject to Approval by the CCHHS Quality and Patient Safety Committee

Alkhudari, Azzam, MD Appointment Effective:

Jones, Joshua D., MD Appointment Effective:

Saad, Jorge, MD Appointment Effective:

INITIAL APPOINTMENT APPLICATIONS

Anesthesiology/Pain Management April17, 2012 thru April16, 2014

Medicine/Pulmonary April17, 2012 thru April16, 2014

Family Medicine/ACHN April 17,2012thruApril 16,2014

REAPPOINTMENT APPLICATIONS

Department of Anesthesiology

Malhotra, Neelam, MD Reappointment Effective:

Obstetrics Anesthesia May 18, 2012 thru May 17, 2014

Department of Correctional Health Services

Yoo, Kyung, MD Reappointment Effective:

Radiology April 30, 2012 thru April 29, 2014

Department of Emergency Medicine

Bower-Lewis, Rebecca, MD Emergency Medicine Reappointment Effective: May 20, 2012 thru May 19, 2014

Bowman, Steven, MD Reappointment Effective:

Feldman, Robert, MD Reappointment Effective:

Flippin, Ardena, MD Reappointment Effective:

Lei kin, Jerrold, MD Reappointment Effective:

Roxas, Roderick, MD Reappointment Effective:

Scaletta, Thomas, MD Reappointment Effective:

Emergency Medicine May 18, 2012 thru May 17, 2014


Emergency Medicine April 30, 2012 thru April29, 2014


Emergency Medicine May 18, 2012 thru May 17,2014


Active Physician

Voluntary Physician

Active Physician

Active Physician

Active Physician

Active Physician

Active Physician

Active Physician

Honorary Physician

Voluntary Physician

Consulting Physician

Honorary Physician

Sergei, Michelle, MD Emergency Medicine Active Physi~· n -, Reappointment Effective: May 18, 2012 thru May 17, 2014 CCHHS - ..

ltemVIII(A)-Aprill7,2012 APPROVED CCHHS Quality and Patient Safety Committee Meeting Page 1 of ~y THE QUALITY AND PATIENT SAFETY OMMITTEE

ON APRIL 17,2012

John H. Stroqer. Jr. Hospital of Cook County Reappointment Applications (continued)

Department of Family Medicine

Donelson, Debbie, MD Reappointment Effective:

Department of Medicine

Ahmed, Wasay Uddin, MD Reappointment Effective:

Sadri, Sheila M., MD Reappointment Effective:

Bartt, Russell E., MD Reappointment Effective:

Danel, Isabella A., MD Reappointment Effective:

Deamant, Catherine D., MD Reappointment Effective:

Disavino, Elia M., MD Reappointment Effective:

Dixon, Kimberly F., MD Reappointment Effective:

EI-Khadra, Maan S., MD Reappointment Effective:

Feldman, Jerry, MD Reappointment Effective:

French, Audrey L., MD Reappointment Effective:

Harris, Alan A., MD Reappointment Effective:

Hayden, Mary K., MD Reappointment Effective:

Hinkamp, David L., MD Reappointment Effective:

Kelleher, Patricia, MD Reappointment Effective:

Family Medicine April19, 2012 thru April18, 2014

General Medicine May 20, 2012 thru May19, 2014

Infectious Disease May 16, 2012 thru May 15, 2014

Neurology May 20, 2012 thru May 19, 2014

General Medicine May 14, 2012 thru May 13, 2014


Neurology May 16, 2012 thru May 15, 2014


Adult Cardiology May 7, 2012 thru May 6, 2014

Dermatology May 20, 2012 thru May 19, 2014




Pulmonary/Occ. Med May 16, 2012 thru May 15, 2014


Active Physician

Active Physician

Active Physician

Active Physician

Voluntary Physician

Active Physician

Voluntary Physician

Active Physician

Active Physician

Active Physician

Active Physician

Active Physician

Voluntary Physician

Voluntary Physician

Active Physician

CCHHS n Item VIII(A)- April 17, 2012

CCHHS Quality and Patient Safety Committee Meeting

APPROVED ~ Page 2 of3JY THE QUALITY AND PATIENT SAFETY COMMITTEE

ON APRIL 17,2012

John H. Stroger. Jr. Hospital of Cook County Reappointment Applications Department of Medicine (continued)

Kelly, Michael A., MD Reappointment Effective:

Kessler, Harold A., MD Reappointment Effective:

Kudaravalli, Padma, MD Reappointment Effective:

Me Dunn, Susan H., MD Reappointment Effective:

Murray, Linda R., MD Reappointment Effective:

Orris, Peter, MD Reappointment Effective:

Proia, Laurie A., MD Reappointment Effective:

Quesada, Nancy M. R., MD Reappointment Effective:

Sadowski, Laura S., MD Reappointment Effective:

Sequeira, Winston, MD Reappointment Effective:

Sha, Beverly E., MD Reappointment Effective:

Tanwar, Sonia, MD Reappointment Effective:

Telfer, Margaret C., MD Reappointment Effective:

Trenholme, Gordon M., MD Reappointment Effective:

Weinstein, Robert A., MD Reappointment Effective:

Neurology May 16,2012 thru May 15, 2014

Infectious Disease May 16,2012 thru May 15,2014

General Medicine May 16,2012 thru May 15,2014

Medical Oncology May 7, 2012 thru May 6, 2014

General Med/Occ. Med. May 20, 2012 thru May 19, 2014

Occ. Med. May 16, 2012 thru May 15, 2014

Infectious Disease May 16,2012 thru May 15,2014

Pulmonary/Critical Care May 7, 2012 thru May 6, 2014


Rheumatology May 20, 2012 thru May 19, 2014

Infectious Disease May 16,2012 thru May 15, 2014

General Medicine April 30, 2012 thru April29, 2014

Hematology/Oncology May 16, 2012 thru May 15, 2014

Infectious Disease May 16, 2012 thru May 15,2014


Active Physician

Voluntary Physician

Active Physician

Active Physician

Affiliate Physician

Voluntary Physician

Voluntary Physician

Active Physician

Voluntary Physician

Voluntary Physician

Voluntary Physician

Active Physician

Active Physician

Voluntary Physician

Active Physician

APPROVED CCHHS £

BY THE QUALITY AND PATIENT SAFETY. MITTEE

ItemVIII(A)-Aprill7,2012 ON APRIL 17,2012

CCHHS Quality and Patient Safety Committee Meeting Page 3 of5

John H. Stroger. Jr. Hospital of Cook County Reappointment Applications (continued)

Department of Obstetrics and Gynecology

Linn, Edward, MD Reappointment Effective:

Tennery, Stephanie, MD Reappointment Effective:

Department of Pathology

Ferrer, Karen, MD Reappointment Effective:

Firfer, Bourke, MD Reappointment Effective:

Kennedy, John, MD Reappointment Effective:

Department of Radiology

Egofske, Peter, MD Reappointment Effective:

Department of Surgery

Kanard, Robert, MD Reappointment Effective:

Obstetrics and Gynecology May 20, 2012 thru May 19, 2014

Gynecology May 18, 2012 thru May 17, 2014

Anatomic Pathology May 18,2012 thru May 17, 2014

Pathology May 18,2012 thru May 17, 2014

Anatomic Pathology May 18, 2012 thru May 17, 2014

Special Procedures May 18,2012 thru May 17, 2014

Pediatric Surgery April17, 2012 thru April16, 2014

Non-Medical Staff Additional Clinical Privileges

Schowalter, Karlene R., CNP Medicine/General Medicine With Krantz, Anne J., MD

Active Physician

Active Physician

Active Physician

Active Physician

Consulting Physician

Active Physician

Active Physician

Nurse Practitioner

APPROVED CCHHS ~

BY THE QUALITY AND PATIENT SAFETY ITTEE ON APRIL 17,2012 ItemVIII(A)-April 17,2012

CCHHS Quality and Patient Safety Committee Meeting Page 4 of5

Provident Hospital of Cook County

Medical Staff Reappointments and Non-Medical Staff Action Items Subject to Approval by the CCHHS Quality and Patient Safety Committee

INITIAL APPOINTMENT APPLICATIONS

Non-Medical Staff Initial Privileges: Baldauff, Leah J., PA-C With Szatkowski, Jan Paul, MD Alternate Crawford, Clifford S., MD Appointment Effective:

Kirkpatrick, Jessica L., PA-C With Szatkowski, Jan Paul, MD Alternate Crawford, Clifford S., MD Appointment Effective:

Surgery Physician Assistant

April17, 2012 thru April16, 2014

Surgery Physician Assistant

April17, 2012 thru April16, 2014

REAPPOINTMENT APPLICATIONS

Department of Emergency Medicine Jackson, Ralph, MD Reappointment Effective:

Department of Family Medicine Barberousse, Lionel, MD Reappointment Effective:

Donelson, Debbie, MD Reappointment Effective:

Department of Internal Medicine Me Dunn, Susan H., MD Reappointment Effective:

Quesada, Nancy M., MD Reappointment Effective:

Rosen, Fred R., MD Reappointment Effective:

Emergency Medicine Active Physician April17, 2012 thru April16, 2014

Family Medicine Active Physician May 16, 2012 thru May 15, 2014

Family .Medicine Active Physician April19, 2012 thru April18, 2014

Hematology/Oncology Affiliate Physician May 18,2012 thru May 17,2014

Pulmonary Medicine Affiliate Physician May 16, 2012 thru May 15, 2014

Oncology Affiliate Physician May 18, 2012 thru May 17, 2014

Department of Obstetrics and Gynecology Malapati, Radha, MD 08/GYNE Affiliate Physician Reappointment Effective: April 30, 2012 thru April 29, 2013

Department of Surgery

Burke, Winston, DPM Reappointment Effective:

Item VIII(A)- April 17, 2012

CCHHS Quality and Patient Safety Committee Meeting

Podiatry Active Podiatrist April17, 2012 thru April16, 2014

CCHHS ~ APPROVED

BY THE QUALITY AND PATIENT SAFETY MITTEE ON APRIL 17,2012

Page 5 of5

CCHHS QPSCCHHS QPSACHN Q a te l Repo tACHN Q a te l Repo tACHN Quarterly ReportACHN Quarterly Report

April 2012April 2012pp

1 Indicator Tracking1. Indicator Tracking2. Cerner Ambulatory:

Prevention & Treatment PromptsMERS Pt S f t d C l i t T ki3. MERS: Pt. Safety and Complaint Tracking

4. PPR, Grants and Other Projects

1

Page 1 of 20

Clinical Indicators 2012Target

Benchmark2011 Actual

2012Q1 actual g

Peds Immunization 82% 72% *NCQA 79% 88%

HgbA1c Current 85% 82% *NCQA 90% 92.5

H bA1 >9 0 25% 29% NA 22% HgbA1c >9.0 <25% <29% *NCQA NA 22%

LDL 82% 81% *NCQA NA 85%

Prenatal Flu Vaccine 80% 49% *CDC 47% NA

Pt Satisfaction mean score

2012 target

Press GaneyPeer Group

2011 actual

2012Q1 actual

Overall 86 85.9 75.7 75.3

Provider 90 89.7 82.6 81.4

Nsg/Support Staff 90 89.2 76.9 78.2

i fPatient Safety 2012 target TJC threshold 2010 actual 2011 actual

Med Reconciliation 100% 90% 64% 92%

UP Time-Out 100% 90% NA 99%

Nail Hygiene 100% 90% 76% 85%

Patient Id 100% 90% 94% 100%2

Page 2 of 20

Prenatal Influenza VaccinationPrenatal Influenza Vaccination80.00%

Prenatal Influenza VaccinationPrenatal Influenza Vaccination

50.00%

60.00%

70.00%

30.00%

40.00%

50.00%

Sept-Dec 2011

10.00%

20.00%

p

0.00%

3

Page 3 of 20

Cerner Ambulatory Power ChartCerner Ambulatory Power Chartyy

July 2012 Pilot ImplementationAugust 2012 Go-LiveAugust 2012 Go-Live

QI Components:-Screening and Treatment Prompts-PQRS -Results Pools and Proxy Capability-Message Center Message Center -CPOE-Electronic Results Endorsement

4

Page 4 of 20

Other Projects and GrantsOther Projects and Grants

Joint Commission PPR◦ Process related indicators

MERS◦ Incident and Complaint tracking

G tG tGrantsGrants CMMI: Center for Medicare and Medicaid Innovation

1115 W i 1115 Waiver ICAAP: Illinois Chapter, American Academy of Pediatrics

5

Page 5 of 20

THANK YOU!

6

Page 6 of 20

4/9/2012

Ambulatory and Community Health Network February 2011 to March 2011 Comparison

FEB % Calls Global Average MAR % Calls Global Average

2011 Captured Score Answer

Time 2011 Captured Score Answer

Time

Austin 86 79 1 min 3 sec Austin 89 77 1 min 2 sec

Prieto 85 66 36sec Prieto 92 69 1 min 5 sec

Cicero 83 74 12 sec Cicero 94 90 14 sec

Woodlawn 89 81 45sec Woodlawn 90 84 54 sec

Near South 85 63 1 min 21 sec Near South 87 62 2 min 28 sec

Logan 90 84 40 sec Logan 95 92 33 sec

Englewood 71 37 2 min 22 sec Englewood 88 57 2 min 19 sec

Cottage 72 45 2min 20 sec Cottage 87 56 1 min 57 sec

Robbins 50 34 3 min 46 sec Robbins 60 38 8 min 49 sec

WWHC 70 68 39 sec WWHC 77 71 48 sec

Sengstacke 54 37 3 min 22 sec Sengstacke 66 38 12 min 26 sec

Central Apt 58 35 1 min 52 sec Central Apt 76 53 1 min 48 sec

Call Center 66 27 3 min 48 sec Call Center 76 36 3 min 49 sec

Page 7 of 20

4/9/2012

Ambulatory and Community Health Network February 2012 to March 2012 Comparison

FEB % Calls Global Average MAR % Calls Global Average

2012 Captured Score Answer

Time 2012 Captured Score Answer

Time

Austin 90 81 41 sec Austin 95 88 29 sec

Prieto 97 89 12 sec Prieto 96 89 12 sec

Cicero 93 91 11 sec Cicero 92 88 9 sec

Woodlawn 94 92 25 sec Woodlawn 93 92 22 sec

Near South 86 56 36 sec Near South 97 89 13 sec

Logan 94 87 16 sec Logan 96 90 19 sec

Englewood 93 79 23 sec Englewood 97 81 19 sec

Cottage 82 58 1 min 23 sec Cottage 88 65 43 sec

Robbins 77 51 44 sec Robbins 77 52 1 min 10 sec

WWHC 88 75 10 sec WWHC 96 79 8 sec

Sengstacke 81 50 1 min 16 sec Sengstacke 78 52 1 min 18 sec

Central Apt 82 53 39 sec Central Apt 89 74 24 sec

Call Center 92 71 18 sec Call Center 90 60 48 sec

Page 8 of 20

Building Community-Based Medical Homes f ACHNfor ACHN

• ACHN; IL Chapter of the American Academy of Pediatrics (ICAAP); and Division of Specialized Care for Children (DSCC), IL Title V program

• 3 year grant program funded by federal Maternal and Child Health Bureau (with some support from Chicago Community ( pp g yTrust)

• Goals: To spread the Illinois Medical Home Model within the pACHN and provide intensive support to 5 high volume pediatric ACHN centers to establish a medical home quality improvement process

1

Page 9 of 20

Who needs a Medical Home?Who needs a Medical Home?

Children and youth with yspecial health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also condition and who also require health and related services of a type or amount beyond that required by beyond that required by children generally.

--Maternal and Child Health Bureau, 1995Maternal and Child Health Bureau, 1995

2

Page 10 of 20

The Medical Home ModelThe Medical Home Model

Primary Care Medical HomePrimary Care Medical Home

Acute Care

A Ill V

Preventive Care Chronic Condition CareChronic Condition Care

Id f & Acute Illness Visits

Emergency Room Care Well Child Visits

Screening & Identification Identification & Monitoring (Registry)

Care Plans &Hospitalizations

Telephone Triage

Immunizations Care Coordination

CCM Office Visits

Co-management with

Acute Illness Follow-up

Co management with Specialists

Patient Education,Advocacy & Outreach

3

Page 11 of 20

The National Survey of Children with Special H l h C N dHealth Care Needs

13.9 % of CSHCN age 0-17 in Illinoisexpend 40% to 80% of Health Care Costs

for children overallSource: 2005-2006 National Survey

of Children with Special Health Care Needs4

Page 12 of 20

A medical home can:A medical home can:

• Form active partnerships with p pfamilies

• Identify and monitor CYSHCN • Coordinate care in a • Coordinate care in a

systematic manner• Communicate with community

d di i i li resources and pediatric specialists • Develop meaningful use of EMRs

and HIT

This requires somere-design of existing services

5

Page 13 of 20

Quality Improvement ProcessQuality Improvement Process• Outside facilitators (provided by ICAAP & DSCC)

• Meetings are regularly scheduled (usually once a month)

• Minimum ACHN team members: 2 parents + at least 1 physician + nursing coordinator and other nursing staff +

clinic administrator or a clerical representative

• Baseline and Follow Up Measurementp

• Develop plans and implement change for quality improvement

• Two Learning Sessions (April September 2012)• Two Learning Sessions (April, September 2012)

• Developmental screening quality improvement initiative

• Transitioning youth to adult health care training

• Mentor Team: Fantus’ Pediatric Medical Home Clinic 6

Page 14 of 20

ACHN Highest Volume Pediatric SitesACHN Highest Volume Pediatric Sites

• Fantus Pediatrics

• Vista

• Cicero

• Logang

• Cottage Groveg

7

Page 15 of 20

ACHN Patient Flows: Arrival to Discharge ACHN Patient Flows: Arrival to Discharge gg

248

200

250248

Oct Apr

150

9199 96 98

151 149

132

114

148

110

90

136144 138 135

9098

11097

136

108

131 131

9095

122

149

10697

50

100 9185

90

69

909078 80Standard

0

1

Page 16 of 20

ACHN Patient Flows: Arrival to Registration ACHN Patient Flows: Arrival to Registration gg

40.0039

33

36 Oct Apr

Mean (minutes)

25.00

30.00

35.00

30

33

21

26

2119

10.00

15.00

20.00

8

16

13

98

12

16

5

15

5

10

1414

9

1516

12 1213

19

14 14

6

15

Standard

.00

5.004 5 5

32

2

Page 17 of 20

ACHN Patient Flows: Registration to Nurse IntakeACHN Patient Flows: Registration to Nurse Intake

70.0069

Oct Apr

Mean (minutes)

40.00

50.00

60.00

3337

50

Oct Apr

20.00

30.00

33

21

17 16

22

19

28

1311 11

1821

2826

23

14

19

25

16

23

13

24

18

10

14

18

2422

13

20

Standard

.00

10.00

107

3

Page 18 of 20

ACHN Patient Flows: Nurse Intake to Provider CareACHN Patient Flows: Nurse Intake to Provider Care

120.00

104Oct Apr

Mean (minutes)

80.00

100.00

7071

5861 60 58

Oct Apr

40.00

60.00

26

36

44

29

38

56

48 48

29

4042

35

52

42

49

4338

45

38 39

58

37

20

36

54

29

58

34

Standard

.00

20.00 14

4

Page 19 of 20

ACHN Patient Flows: Provider Care to DischargeACHN Patient Flows: Provider Care to Discharge

70.0068

Mean (minutes)

40.00

50.00

60.00

3740

53

40

4543

44

54

40

3535

4038

34 35

50

20.00

30.00 24

19

31 3132

24

30

23

2826 27

32 3234

26 27 28 28

Standard

.00

10.00

5

Page 20 of 20

QUALITY AND PATIENT SAFETY COMMITTEE AGENDA · 2012-04-17 · QUALITY AND PATIENT SAFETY COMMITTEE...

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