1. IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD % Perfection Worksite Safety Indicators Blood Borne Pathogen Exposures--Sharps0? 3.85 (6) 1.20 (2) 2.35 (4) 0.60 (1) 1.79 (3) 1.18 (2) 1.16 (2) 1.70 (3) 1.78 (3) 2.27 (4) 2.99 (5) 3.03 (5) 1.98 (40) 53.2 Patient Safety Indicators (PSI) PSI Composite Score for Patient SafetyB.L.HC?0.800.870.720.800.670.79 0.89 1.001.100.84B.L. PSI 04 Death Among Surgical Inpatients With Serious Treatable Complications 0HC?0000000000000100 PSI 06 Iatrogenic Pneumothorax, Adult0HC?0 0.13 (1) 0 0.27 (2) 0.13 (1) 0 00 0.14 (1) 0.09 (8) 99.9 PSI 11 Post-op Respiratory Failure0HC? 0.13 (1) 00000000000 0.01 (1) 99.9 PSI 12 Post-op Pulmonary Embolism/DVT0HC?0 1.38 (2) 000 0.70 (1) 00 0.76 (1) 2.01 (3) 0 0.49 (8) 99.5 PSI 14 Percent of Postoperative Wound Dehiscence 0HC?0000000000000100 PSI 15 Accidental Puncture or Laceration0HC?000 0.12 (1) 0.13 (1) 0.12 (1) 0.13 (1) 00 0.25 (2) 0 0.07 (7) 99.9 Safety  Quality  Service  Relationships  Performance Task List Task List Goal = Perfection ? = Explanation/Calculation HC = Hospital Compare SOMCSafety Dashboard – FY 13 Patient-Centered Perfection is the Goal

2. IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD % Perfection Inpatient Quality Indicators (IQI) Mortality Measures IQI Composite Score for Mortality for Selected Medical Conditions B.L.HC?1.140.950.990.960.830.950.941.120.980.990.960.990.98B.L. IQI 11 Abdominal Aortic Aneurysm (AAA) Repair Mortality 0?N/A00 000 00000100 IQI 19 Mortality Hip Fracture0HC? 7.69 (1) 00 40.0 (2) 00000000 3.90 (3) 96 AMI 30 day Non-Risk Standardized Mortality Rate – SOMC Internal Report 0HC?0 12.50 (1) 11.76 (2) 0000 10.00 (1) 0 9.09 (1) 00 4.17 (5) 96.4 HF 30 day Non-Risk Standardized Mortality Rate –SOMC Internal Report 0HC? 16.67 (2) 12.50 (2) 20.00 (2) 5.88 (1) 0 5.56 (1) 6.67 (1) 0 4.35 (1) 26.32 (5) 4.55 (1) 8.33 (1) 8.85 (17) 90.8 PN 30 day Non-Risk Standardized Mortality Rate – SOMC Internal Report 0HC? 22.22 (2) 10.00 (1) 8.33 (1) 0 5.88 (1) 10.34 (3) 4.00 (1) 11.11 (1) 0 14.29 (2) 6.67 (1) 5.00 (1) 7.65 (14) 91.8 Safety  Quality  Service  Relationships  Performance SOMCSafety Dashboard – FY 13 Patient-Centered Perfection is the Goal Task List Task List Goal = Perfection ? = Explanation/Calculation HC = Hospital Compare

3. Safety  Quality  Service  Relationships  Performance Tasklist Tasklist Goal = Perfection ? = Explanation/Calculation HC = Hospital Compare SOMCSafety Dashboard – FY 13 Patient-Centered Perfection is the Goal IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD % Perfection Readmission Rate Indicators AMI 30 day Non-Risk Standardized Readmission Rate - SOMC Internal Report 0HC 44.4 (4) 14.29 (1) 13.33 (2) 27.27 (3) 20.00 (2) 31.25 (5) 28.57 (2) 25.00 (3) 60.00 (6) 33.33 (4) 8.33 (1) 27.27 (3) 27.27 (36) 72.2 HF 30 day Non-Risk Standardized Readmission Rate - SOMC Internal Report 0HC 12.5 (1) 25.0 (4) 14.29 (2) 18.52 (5) 28.57 (6) 18.18 (4) 31.58 (6) 9.09 (1) 20.83 (5) 10.00 (2) 18.18 (4) 6.67 (1) 18.72 (41) 82.2 PN 30 day Non-Risk Standardized Readmission Rate - SOMC Internal Report 0HC 28.6 (2) 10.0 (1) 7.14 (1) 21.05 (4) 21.62 (8) 7.41 (2) 10.00 (1) 0 20.00 (3) 18.75 (3) 20.00 (4) 15.71 (33) 84.5 Hospital –Wide All –Cause Unplanned Readmission Measure (HWR) B.L.? 14.88 (43) 12.80 (41) 12.68 (36) 11.51 (35) 14.69 (47) 14.94 (52) 12.33 (36) 17.52 (46) 16.55 (47) 15.31 (49) 18.35 (58) 15.05 (31) 14.50 (521 85.7 Hospital-Level 30-Day All-Cause Risk- Standardized Readmission Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total knee Arthroplasty (TKA) B.L.?00 20.00 (3) 0 16.67 (2) 20.00 (1) 16.67 (1) 0 25.00 (1) 14.29 (1) 12.50 (1) 0 10.87 (10) 89.6 Patient Safety Outpatient Imaging Efficiency Indicators MRI Lumber Spine for Low Back Pain0HC? 9174 88837357483733323628 5444.3 Mammography Follow-up Rates8-14%HC?13 14 2211161214131113 14 98 Abdomen CT – Use of Contrast Material 0HC?8.46 10.7 6.961417913161740.6509.5890.3 Thorax CT Use of Contrast Material0HC?4.26 10.1 7.144.302.561514 131.23006.2292.4 Simultaneous use of Brain CT and Sinus CT 0HC?4.80 3.68 1.491.826.521.211.123.671.011.461.470.832..3490.0

4. IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD % Perfection Patient Safety Outpatient Imaging Efficiency Indicators Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery 0HC? 3.85 (2) 1.64 (1) 0 3.70 (2) 2.94 (2) 1.61 (1) 3.70 (2) 3.00 (3) 4.69 (3) 2.67 (2) 1.35 (1) 2.74 (2) 2.61 (21) 97.3 ED Outpatient Measure Left Without Being Seen0?2.012.131.140.670.800.950.320.391.090.650.410.780.9799.0 Patient Safety Hospital Acquired Infection Indicators Catheter-Associated Vascular Infection * 0HC?0 1.75 (1) 000 1.53 (1) 0000 1.37 (1) 0 0.40 (3) 75.0 Catheter-Associated UTI *0HC?0 1.62 (2) 0000 1.90 (3) 0.77 (1) 0000 0.38 (6) 75.0 Ventilator Associated Pneumonia0?0000000000000100 Mediastinitis After CABG *0?0000000000000100 SSI In Deep Open Heart Patients * (Non-risk Adjusted) Expected Rate 0?0000000000000100 SSI in Colon Surgeries0HC?0000000000000100 SSI in Total Abdominal Hysterectomy (TAH) Surgeries) 0HC?00000000000 7.69 (1) 0.58 (1) 91.7 Safety  Quality  Service  Relationships  Performance SOMCSafety Dashboard – FY 13 Patient-Centered Perfection is the Goal Tasklist Tasklist Goal = Perfection ? = Explanation/Calculation HC = Hospital Compare *Hospital-Acquired Conditions

5. Safety  Quality  Service  Relationships  Performance IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD % Perfection SSI in Deep C-Section Patients *0?00000000 3.23 (1) 000 0.27 (1) 91.7 SSI Deep in Knee Replacements *0? 10.00 (2) 0 3.70 (1) 000000 8.33 (1) 00 2.27 (4) 75.0 C.Diff Acquired While in Hospital *0? 0.21 (1) 0 0.19 (1) 0.16 (1).40 (2) 0.19 (1) 0.41 (2) 0.38 (2) 0 0.58 (3) 0.40 (2) 0.25 (16) 92.0 MRSA Blood Stream Infection Acquired While in Hospital * 0?0000000000000100 MSSA Blood Stream Infection Acquired While in Hospital * 0?0000000000000100 MRSA & MSSA Blood Stream Infection Acquired While in Hospital * 0?0000000000000100 CMS Hospital Acquired Conditions Patient Retention of Foreign Object After Surgery or Death * 0HC?0000000000000100 Hemolytic /Reaction due to Incompatible Blood Product * 0HC?0000000000000100 Falls & Trauma *0HC? 0.21 (1) 0.20 (1) 0.19 (1) 0.58 (3) 00 0.19 (1) 00 0 0.40 (2) 0.16 (10) 98 SOMCSafety Dashboard – FY 13 Patient-Centered Perfection is the Goal Tasklist Tasklist Goal = Perfection ? = Explanation/Calculation HC = Hospital Compare *Hospital-Acquired Conditions

6. Safety  Quality  Service  Relationships  Performance IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD % Perfection Stage 3 & 4 Pressure Ulcers0HC? 0.21 (1) 00000 0.19 (1) 00000 0.03 (2) 88.9 Air Embolus *0HC?0000000000000100 Manifestations of Poor Glycemic Control 0HC?0000000000000100 Non-Risk Adjusted Complication Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total knee Arthroplasty (TKA) within 7, 30, and 90 Days (SOMC Internal Report) 0?0 11.11 (1) 13.33 (2) 00 20.00 (1) 00 25.00 (1) 14.29 (1) 00 6.52 (6) 73.0 National Quality Forum (NQF) Never Events Serious Safety Events (SSE)0?111100130110 0.8 (10) 33 Never Events (Rollup)0?0000000000000100 Leapfrog Safety Score Hospital Safety Score 100% “A” ? 3.21 “A” 3.2181.7% Rate of Perfection:100%90.0% SOMCSafety Dashboard – FY 13 Patient-Centered Perfection is the Goal Tasklist Tasklist Goal = Perfection ? = Explanation/Calculation HC = Hospital Compare * Hospital-Acquired Conditions

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