Clinical Excellence Report

Quality Improvement Committee February 25, 2015

George Block, MD, CMO

A Member of Daughters of Charity Health System

Framework for Clinical Excellence

Measures that align national initiatives to the front line

VBP VBP VBP PFP VBP PFP VBP $ $

Heart Failure, Heart Attack, Pneumonia, Sepsis, VTE, Stroke, EED HCAHPS Overall Rating 9-10 Likelihood to Recommend Risk Adjusted Mortality Ratio Sepsis, Palliative Care PSI 90 (QUEST Harm Index) 30-day all cause readmissions Length of Stay ALOS

O’Connor Clinical Performance: (FY15) February 2015

Latest Month

Patient Experience (Top box 9/10) Core Measures Mortality 71% (Jan) 90.8% (Dec) 0.82 (Nov) YTD/M 71.3% 94.4% 0.94

Harm (Medicare Only) N/A 0.40 (Nov) Readmissions (Medicare only) ALOS-GMLOS (Medicare Only) 0.92 (Nov) 0.40 (Jan) 0.93

0.77

Goal 75% 96% 0.85

0.62

0.88

0.0