Risk Management Report for Vila Health: Mercy Hospital Safety and Quality Dashboard

• Vila Health: Mercy Hospital Safety and Quality Dashboard

The provided information outlines various safety and quality metrics from different departments at Vila Health’s Mercy Hospital. Each metric has a specified target, and the results are reported for January, February, and March. The data includes measures related to operational efficiency, quality of care, patient safety, and patient satisfaction across different hospital units like Physical Therapy, Endoscopy, Infection Control, Laboratory, ICU/PCU, and the Emergency Room.

Here’s a brief summary of each department’s performance:

### 1. **Physical Therapy**
– **Early Intervention**: The goal is for PT to respond to consults within 24 hours. The target is 100%, with performance improving from February’s 79.5% (D) to 96% (C) in March, though it still didn’t meet the target.
– **Quality**: The percentage of patients meeting 75% of their goals upon discharge was consistently at 100%, meeting the target across all months.

### 2. **Endoscopy**
– **Patient Satisfaction**: The target was 95% satisfaction with wait times. Performance declined from meeting the target in January to 88% (D) in March, failing to meet the target.

### 3. **Infection Control**
– **CAUTI Rate**: The target was a rate below 1.1%. After failing in February with 1.6% (C), the rate improved to 0% in March, meeting the target.
– **Hand Hygiene**: The goal was 98% compliance with hand hygiene, but this was not met, with March showing an improvement to 93% (C) after dipping to 88% (D) in February.

### 4. **Laboratory**
– **Critical Lab Values**: The target for communicating critical lab values from RN to physician within 20 minutes was 100%. This was consistently poor, with the best performance being 76.6% (D).
– **ER Lab Turnaround Time (TAT)**: The target was 92% for ER receipt to results, which was consistently met and exceeded, reaching over 93% each month.

### 5. **ICU/PCU**
– **Discharge Education**: The goal was 100% documentation of discharge education, consistently met across all months.
– **Medication List at Discharge**: Also met the 100% target consistently.
– **Patient Fall Rate**: The target was less than 2% for falls. The rate exceeded this target in March, reaching 3.3% (D), after meeting the target in the previous months.
– **MRSA Swab Collection**: The target was 100%, but performance improved only to 84.4% (C) by March.

### 6. **Emergency Room**
– **EKG for Chest Pain**: The goal was to perform EKGs within 10 minutes of arrival. This was met in January and February but dropped drastically to 17% (D) in March.
– **Pain Assessment and Intervention**: The target was 100% for documentation of pain assessment and appropriate interventions. This was consistently poor, with March showing slight improvement to 76% (D).

These results indicate areas of concern, especially in the Laboratory’s critical value communication and the Emergency Room’s pain assessment protocols. Despite some improvements, consistent failures to meet targets in key safety and quality measures suggest a need for a thorough review and intervention in these areas.

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