1. SOMCQuality Dashboard - FY 12 Patient-Centered Perfection is the Goal Safety  Quality  Service  Relationships  Performance IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD Improve Quality of Care – AMI Inpatient Aspirin at Arrival for AMI Aspirin at Arrival for AMI $100%HC ?100 95100 95100 99 Aspirin at Discharge for AMI Aspirin at Discharge for AMI $100%HC?100 96100 99 Beta Blocker at Discharge for AMI Beta Blocker at Discharge for AMI $100%HC?100 95100 9710099 ACE Inhibitor/ARB at Discharge for AMI for LVSD less then 40 ACE Inhibitor/ARB at Discharge for AMI for LVSD less then 40 $ 100%HC?100 Smoking Cessation Advice for AMI Smoking Cessation Advice for AMI $100%HC?100 Door to P.C.I. ≤ 90 Minutes for AMI Door to P.C.I. ≤ 90 Minutes for AMI $100%HC?100 N/A100 Statin at Discharge for AMI $100%?1009610095100 9710099 Improve Quality of Care – CHF Inpatient ACE Inhibitor/ARB at Discharge for CHF for LVSD less than 40 ACE Inhibitor/ARB at Discharge for CHF for LVSD less than 40 $ 100%HC?100 LV Function Assessment for CHF LV Function Assessment for CHF $100%HC?100 96100 99 Smoking Cessation Advice for CHF Smoking Cessation Advice for CHF $100%HC?100 Discharge Instructions for CHF Discharge Instructions for CHF $100%HC?100 95100 99 Improve Quality of Care – C.A.P. Inpatient Blood Culture Before Antibiotic for C.A.PBlood Culture Before Antibiotic for C.A.P. $100%HC?100 98100 98100 99 Antibiotic Timing <6hrs for C.A.P. Antibiotic Timing <6hrs for C.A.P. $100%HC?100 9810099 Appropriate Initial Antibiotic Selection for C.A.P. Appropriate Initial Antibiotic Selection for C.A.P. $ 100%HC?100 97 100 97 9410098 Pneumococcal Vaccine for Eligible Patients Pneumococcal Vaccine for Eligible Patients $100%HC?100 Influenza Vaccine for Eligible Patients (Oct 1st – Mar 31st ) Influenza Vaccine for Eligible Patients (Oct 1st – Mar 31st ) $ 100%HC?N/A 100 Smoking Cessation Advice for C.A.P. Smoking Cessation Advice for C.A.P. $100%HC?100 ? = Explanation/Calculation HC = Hospital Compare Task List Data Sheet $

2. Safety  Quality  Service  Relationships  Performance IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD Immunization Measures Pneumococcal Immunization – Overall Rate $100%?100 9710098 99 Influenza Immunization – Overall Rate $100%?939293N/A 93 Improve Quality of Care – Surgical Inpatient Foley Catheter Removed on POD 1 or POD 2 $100%HC?10097100 97100 99 Normothermia on all Surgical Patients $100%HC?100 Antibiotic Within 1 Hour Before Surgical Incision Antibiotic Within 1 Hour Before Surgical Incision $100%HC?10098 10098 94100 9899 Prophylactic Antibiotic Discontinued Within 24 Hours for Surgery Patients Prophylactic Antibiotic Discontinued Within 24 Hours for Surgery Patients $ 100%HC?100 96100 9810098 100 99 Appropriate Prophylactic Antibiotic Selection for Surgery Patients Appropriate Prophylactic Antibiotic Selection for Surgery Patients $ 100%HC?981009810098 9798100 99 Surgery Patients With Appropriate Hair Removal Surgery Patients With Appropriate Hair Removal $100%HC?100 Major Cardiac Patients with Controlled (<200 mg/dl) 6am Post-op Serum Glucose on POD 1 and POD 2 $ 100%HC?100 9010099 Surgery Patients on Beta Blockers Prior to Admission Who Receive Beta Blocker During Perioperative Period Surgery Patients on Beta Blockers Prior to Admission Who Receive Beta Blocker During Perioperative Period $ 100%HC?100 9596100 99 V.T.E. Prophylaxis Ordered for Surgery Patients V.T.E. Prophylaxis Ordered for Surgery Patients $100%HC?100 98100 9810099 V.T.E. Prophylaxis Received Within 24 Hours Prior to or After Surgery V.T.E. Prophylaxis Received Within 24 Hours Prior to or After Surgery $ 100%HC?98 96100 98 100 98 10099 Improve Quality of Care – Emergency Department Median Time From ED Arrival to ED Departure for Admitted ED Patients ≤283 Minutes (SOMC Report) $ 100%HC ? 100 96100 Admit Decision Time to ED Departure Time for Admitted Patients ≤51 Minutes (SOMC Report) $ 100%HC100 93100598294 ? = Explanation/Calculation HC = Hospital Compare VBP = Value-Based Purchasing $ Task List Data Sheet SOMCQuality Dashboard - FY 12 Patient-Centered Perfection is the Goal

3. Safety  Quality  Service  Relationships  Performance IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD Median Time From ED Arrival to ED Departure for Admitted ED Patients $ B.LHC ? 222240296323290281275 Admit Decision Time to ED Departure Time for Admitted Patients $ B.LHC8479.5113103917190 Stroke Measures - Inpatient Venous Thromboembolism (VTE) Prophylaxis100%?75100869210092100 88100 94 Discharged on Antithrombotic Therapy100%?100 93100 99 Anticoagulation Therapy for Atrial Fibrillation/Flutter100%?N/A100 6750100N/A50100 80 Thrombolytic Therapy100%?00N/A 10033 Antithrombotic Therapy by end of Hospital Day 2100%?10091100 89100 99 Discharged on Statin Medication100%?8810088100 75909210095 Stroke Education100%?100 80851005775100 91 Assessed for Rehabilitation100%?83 100 86100 96 Improve Quality of Care – Surgical Outpatient Appropriate Prophylactic Antibiotic Initiated Within One Hour Prior to Surgical Incision Appropriate Prophylactic Antibiotic Initiated Within One Hour Prior to Surgical Incision $ 100%HC?100 Appropriate Prophylactic Antibiotic Selection for Surgical Patients Appropriate Prophylactic Antibiotic Selection for Surgical Patients $ 100%HC?100 949599 Improve Quality of Care – Chest Pain/AMI Outpatient Aspirin at Arrival For Chest Pain/AMI Aspirin at Arrival For Chest Pain/AMI $100%HC?100 N/A100 6710097 Percent of ECGs for Chest Pain/AMI Meeting the National Median Time of 4 Minutes or Less Prior to Transfer Percent of ECGs for Chest Pain/AMI Meeting the National Median Time of 4 Minutes or Less Prior to Transfer $ 100%HC?10075100 N/A67756001006777 Troponin Results for ED Acute Myocardial Infarction (AMI) Patients or Chest Pain Patients (With Probable Cardiac Chest Pain) Received Within 60 Minutes of Arrival $ B.L.?675040002032 ? = Explanation/Calculation HC = Hospital Compare $ Task List Data Sheet SOMCQuality Dashboard - FY 12 Patient-Centered Perfection is the Goal

4. Safety  Quality  Service  Relationships  Performance IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD Median Time From ED Arrival to ED Departure for ED Patients – Overall Rate $ B.L.?170131166137198148158 Door to Diagnostic Evaluation by a Qualified Medical Personnel $ B.L.?1392148423427.8 Median Time to Pain Management for Long Bone Fracture $ B.L.?59.5447254466757 Left Without Being Seen $B.L.?0.620.191.743.352.331.571.05 Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretations Within 45 Minutes of ED Arrival $ B.L.?0N/A100N/A 10067 Structural Measures Structural Measures $100%?Yes100 YTD Rate of Perfection96.1% ? = Explanation/Calculation HC = Hospital Compare $ Task List Data Sheet SOMCQuality Dashboard - FY 12 Patient-Centered Perfection is the Goal

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