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1Vila Health: Mercy Hospital Safety and Quality Dashboard Legend M = Meets target C = Close to target D = Does not meet target Physical

1

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

2

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

3

  • Vila Health: Mercy Hospital Safety and Quality Dashboard

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