1. IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD Worksite Safety Indicators Total Recordable Injury Incident Rate Never Occurring 100%?0000000000000 Blood Borne Pathogen Exposure Never Occurring 100%?000000100 00 025 Patient Safety Indicators (PSI) PSI Composite Score for Patient Safety Occurring 100%HC?0000000000000 PSI 04 Death Among Surgical Inpatients With Serious Treatable Complications Never Occurring 100%HC?100 0 92 PSI 06 Iatrogenic Pneumothorax, Adult Never Occurring 100%HC?0100 0 0 75 PSI 08 Post-op Hip Fracture Never Occurring 100%?100 PSI 09 Post-op Hemorrhage/Hematoma Never Occurring 100%?100 0 0 075 PSI 11 Post-op Respiratory Failure Never Occurring 100%HC?100 Safety  Quality  Service  Relationships  Performance Task List Task List Goal = Perfection, Percent Never Occurring ? = Explanation/Calculation SOMCSafety Dashboard – FY 12 Patient-Centered Perfection is the Goal

2. IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD PSI 12 Post-op Pulmonary Embolism/DVT Never Occurring 100%HC?000100 0 67 PSI 13 Post-op Sepsis Never Occurring100%?100 PSI 14 Percent of Postoperative Wound Dehiscence Never Occurring 100%HC?100 PSI 15 Accidental Puncture or Laceration Never Occurring 100%HC?00100 0 75 Inpatient Quality Indicators (IQI) Mortality Measures IQI Composite Score for Mortality for Selected Medical Conditions 100%HC?0000000000000 IQI 15 Mortality AMI Never Occurring100%?0000100 0000 34 IQI 16 Mortality CHF Never Occurring100%?0000000000000 IQI 17 Mortality Stroke Never Occurring100%?00000100000 0017 IQI 18 Mortality GI Hemorrhage Never Occurring 100%?100 IQI 19 Mortality Hip Fracture Never Occurring 100%HC?0100 92 IQI 20 Mortality Pneumonia Never Occurring 100%?000000010000009 Safety  Quality  Service  Relationships  Performance SOMCSafety Dashboard – FY 12 Patient-Centered Perfection is the Goal Task List Task List Goal = Perfection, Percent Never Occurring ? = Explanation/Calculation

3. IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD CMS FY 10 AMI 30 day Risk Standardized Mortality no Different Than or Better Than U.S. National Rate 100%HC?00 CMS FY 10 HF 30 day Risk Standardized Mortality no Different Than or Better Than U.S. National Rate 100%HC?00 CMS FY 10 PN 30 day Risk Standardized Mortality no Different Than or Better Than U.S. National Rate 100%HC?00 Readmission Rate Indicators AMI 30 day RISK Standardized Readmission Rate no Different Than or Better Than U.S. National Rate 100%HC00 HF 30 day RISK Standardized Readmission Rate no Different Than or Better Than U.S. National Rate 100%HC00 PN 30 day RISK Standardized Readmission Rate no Different Than or Better Than U.S. National Rate 100%HC00 Safety  Quality  Service  Relationships  Performance Tasklist Tasklist Goal = Perfection, Percent Never Occurring ? = Explanation/Calculation HC = Hospital Compare SOMCSafety Dashboard – FY 12 Patient-Centered Perfection is the Goal

4. IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD Patient Safety Outpatient Imaging Efficiency Indicators MRI Lumber Spine for Low Back Pain at or Below 32.7% 100%HC?00 Mammography Follow-up Rates at 8% up to 14% 100%HC?00 Abdomen CT – Use of Contrast Material at or Below 0.19 100%HC?00 Thorax CT Use of Contrast Material at or Below 0.05 100%HC?00 Simultaneous use of Brain CT and Sinus CT at or below 2.8% 100%HC?00 Use of Brain CT in the ED for Atraumatic Headache at or below 35.1% 100%HC?00 Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery ≤5.2% 100%HC?00 Patient Safety Hospital Acquired Infection Indicators Catheter-Associated Vascular Infection Never Occurring* 100%HC?100 0 0 84 Catheter-Associated UTI Never Occurring* 100%HC?00010000 0 0 034 Mediastinitis After CABG Never Occurring* 100%?100 SSI In Deep Open Heart Patients * (Non- risk Adjusted) Expected Rate 100%?01000 0 75 Safety  Quality  Service  Relationships  Performance * Hospital-Acquired Conditions SOMCSafety Dashboard – FY 12 Patient-Centered Perfection is the Goal Tasklist Tasklist Goal = Perfection, Percent Never Occurring ? = Explanation/Calculation HC = Hospital Compare

5. Safety  Quality  Service  Relationships  Performance IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD SSI in Deep C-Section Patients Never Occurring* 100%?0100 92 SSI Deep in Knee Replacements Never Occurring* 100%?1000000 0 050 C.Diff Acquired While in Hospital Never Occurring* 100%?0100 0 0000 042 MRSA Blood Stream Infection Acquired While in Hospital Never Occurring* 100%?100 0 0 84 MSSA Blood Stream Infection Acquired While in Hospital Never Occurring* 100%?100 MRSA & MSSA Blood Stream Infection Acquired While in Hospital Never Occurring* 100%?100 CMS Hospital Acquired Conditions Patient Retention of Foreign Object After Surgery or Death Never Occurring* 100%HC?100 0 92 Hemolytic /Reaction due to Incompatible Blood Product Never Occurring* 100%HC?100 Falls & Trauma Never Occurring*100%HC?100 0 0 0 75 * Hospital-Acquired Conditions SOMCSafety Dashboard – FY 12 Patient-Centered Perfection is the Goal Tasklist Tasklist Goal = Perfection, Percent Never Occurring ? = Explanation/Calculation

6. Safety  Quality  Service  Relationships  Performance IndicatorGoalHC?JulAugSepOctNovDecJanFebMarAprMayJunYTD Stage 3 & 4 Pressure Ulcers Never Occurring 100%HC?010000000 0 42 Air Embolus Never Occurring *100%HC?100 Manifestations of Poor Glycemic Control Never Occurring 100%HC?100 National Quality Forum (NQF) Never Events Sentinel Events Never Occurring100%?100 00 0 Surgery Performed on the Wrong Body Part Never Occurring 100%?100 Surgery Performed on the Wrong Patient Never Occurring 100%?100 Intraoperative or Immediately Post- Operative Death in an ASA Class I Patient Never Occurring 100%?100 Patient Death or Serious Disability Associated with the use or Function of a Device in Patient Care, in Which the Device is used or functions Other Than as Intended Never Occurring 100%?100 * Hospital-Acquired Conditions SOMCSafety Dashboard – FY 12 Patient-Centered Perfection is the Goal Tasklist Tasklist Goal = Perfection, Percent Never Occurring ? = Explanation/Calculation

7. Safety  Quality  Service  Relationships  Performance IndicatorGoal?JulAugSepOctNovDecJanFebMarAprMayJunYTD Patient Death or Serious Disability Associated with Intravascular Air Embolism that Occurs While Being Cared for in a Healthcare Facility Never Occurring 100%?100 Infant Discharge to the Wrong Person Never Occurring 100%?100 Patient Death or Serious Disability Associated with Patient Elopement Never Occurring 100%?100 Patient Suicide or Attempted Suicide Resulting in Serious Disability, While Being Cared for in a Healthcare Facility Never Occurring 100% ? 100 Patient Death or Serious Disability Associated with a Medication Error Never Occurring 100% ? 100 Maternal Death or Serious Disability Associated with Labor or Delivery in a Low-risk Pregnancy While Being Cared for in a Healthcare Facility Never Occurring 100% ? 100 Patient Death or Serious Disability Associated with Hypoglycemia, the Onset of Which Occurs While the Patient is Being Cared for in a Healthcare Facility Never Occurring 100% ? 100 Patient-Centered Perfection is the Goal SOMCSafety Dashboard – FY 12 Patient-Centered Perfection is the Goal Tasklist Tasklist Goal = Perfection, Percent Never Occurring ? = Explanation/Calculation

8. Safety  Quality  Service  Relationships  Performance IndicatorGoal?JulAugSepOctNovDecJanFebMarAprMayJunYTD Death or Serious Disability (Kernicterus) Associated with Failure to Identify and Treat Hyperbilirubinemia in Neonates Never Occurring 100%?100 Patient Death or Serious Disability due to Spinal Manipulative Therapy Never Occurring 100%?100 Patient Death or Serious Disability Associated with an Electric Shock While Being Cared for in a Healthcare Facility Never Occurring 100%?100 Any Incident in Which a Line Designated for Oxygen or Other gas to be Delivered to a Patient Contains the Wrong Gas or is Contaminated by Toxic Substances Never Occurring 100%?100 Patient Death or Serious Disability Associated with a Burn Incurred from any Source While Being Cared for in a Healthcare Facility Never Occurring 100%?100 Patient Death or Serious Disability Associated with a Fall While Being Cared for in a Healthcare Facility Never Occurring 100%?100 Patient Death or Serious Disability Associated with the use of Restraints or Bedrails While Being Cared for in a Healthcare Facility Never Occurring 100%?100 Patient-Centered Perfection is the Goal SOMCSafety Dashboard – FY 12 Patient-Centered Perfection is the Goal Tasklist Tasklist Goal = Perfection, Percent Never Occurring ? = Explanation/Calculation

9. Safety  Quality  Service  Relationships  Performance IndicatorGoal?JulAugSepOctNovDecJanFebMarAprMayJunYTD Any Instance of Care Ordered by or Provided by Someone Impersonating a Physician, Nurse, Pharmacist or other Licensed Healthcare Provider Never Occurring 100%?100 Abduction of a Patient of any age Never Occurring 100%?100 Sexual Assault on a Patient Within or on the Grounds of the Healthcare Facility Never Occurring 100%?100 Patient Death or Significant Injury of a Patient or Staff Member Resulting From a Physical Assault that Occurs within or the Grounds of the Healthcare Facility Never Occurring 100%?100 Patient Death or Serious Disability Associated with the use of Contaminated Drugs, Devices, or Biologics Provided by the Healthcare Facility Never Occurring 100%?100 YTD Rate of Perfection64.3% SOMCSafety Dashboard – FY 12 Patient-Centered Perfection is the Goal Tasklist Tasklist Goal = Perfection, Percent Never Occurring ? = Explanation/Calculation

10. S a f e t y  Q u a l i t y  S e r v i c e  R e l a t i o n s h i p s  P e r f o r m a n c e What questions do you have? www.somc.org