1. Quality How is this LOM Metric measured in the LEM?
Heart Failure Mortality
Pneumonia Mortality
Acute Myocardial Infarction Mortality (Heart Attack)
Central line associated blood stream infection (NHSN)
Catheter associated urinary tract infection (NHSN)
Surgical Site Infection: Colon (NHSN)
Surgical Site Infection: Abdominal Hysterectomy (NHSN)
Ongoing Tactics and Current Performance for this LOM Metric
Interdisciplinary CAUTI/CLABSI Steering Team
BARD Assessment of Practices (SVI and SVHS)
Recommendations
Education May and June 2017
Vascular Access Team REFRESH (SVI)
Encouraging Blood Culture Draws from Peripheral Sites
SVHS and Pilot at SVI
Supply Evaluation on-going
Coming Soon!! Senior Leading Round for CAUTI/CLABSI
Where can you fit in to this measure?
HAND WASHING: Four of the seven quality metrics are related to Infections
Accountability for Bundle Compliance (CAUTI and CLABSI)
Continuum of Care Opportunities for Heart Failure Patients. Readmission prevention through follow up visits with PCP or Heart Failure Specialist.
The aim of leadership is not merely to find and record failures of men, but to remove the causes of failure.
–Charles Deming on Leadership

2. Safety How is this LOM Metric measured in the LEM?
Pressure Ulcers; hospital acquired
Post Operative Hip Fracture
Iatrogenic Pneumothorax
Central Line Associated Blood Stream Infections (Coded)
Post Operative Sepsis
Post Operative Wound Dehiscence
Periop Pulmonary Embolism or Deep Vein Thrombosis
Accidental Punctures or Lacerations
Ongoing Tactics and Current Performance for this LOM Metric
System Wide Falls Team
TRIZ Training; Posey Bed Alarms, Falls Mats Instituted
Concurrent Review for VTE Prophylaxis
System Wide Pressure Ulcer Team
Quarterly Prevalence Studies
Sepsis Education with Physicians
Coming Soon: Performance Excellence Tool in Cerner!
Where can you fit in to this measure?
No Pass Zone! (SVHS)
Utilize and encourage principals from your Safety First Training. Empower your Safety Coaches!
Teaching the world to be careful is a constructive service, worthy of God’s great gift of life to man.
-US Supreme Court Justice Harold H. Burton