7.1 Summarize your organization s KEY health care RESULTS. Segment your RESULTS by PATIENT and other CUSTOMER groups and market SEGMENTS, as appropriate. Include appropriate comparative data. Indicate those MEASURES that are mandated by regulatory, accreditor, or payor requirements. AMI Process Inpatient Diabetes Mean Blood Glucose Level Cardio Vascular Service Line Acute Myocardial Infarction Overall Mortality Total Mortality Medicare Marketplace Comparison Acute Myocardial Infarction Betablocker At Arrival Unplanned Readmissions Within 31 Days AMI Mortality Total Mortality CAH Total Mortality CAP Process CAP Mortality Surgical Wound Infections Cardio Vascular Medical ICU Diabetes Service Line Average Blood Glucose Levels Coronary Artery Bypass Graft Medicare Mortality CHF Mortality Glycemic Control Percentage In Joint Replacement Patients AMI Beta Blockers At DC CAP Appropriate Antibiotic Selection Non ICU AMI Mortality RoMACC On Discharge Cardio Vascular/Medicine Service Lines CHF AF Mortality MI Mortality ED/Surgical Service Lines ED/Surgical (CCU) Service Line Tracheostomy AMI Mortality Simple Pneumonia Mortality ED/Surgical Service Line Craniotomy Stroke Mortality Professional Support Service Line Increased Patient Function After Antibiotic Within 4 Rehab Hours Stroke Mortality s Pneumonia Mortality s MI Treatment Indicators CHF Treatment Indicators Consumer's Checkbook Ratings VHA Green Light Project Surgical Infection/Antibiotics Within 1 Hour of Incision Hip/Knee Arthoplasty Antibiotics Within 1 Hour of Incision Core CHF Acute Myocardial Infarction Smoking Cessation Counseling Acquired Pneumonia Blood Cultures Obtained Pressure Ulcers Medication Event Compliance With Restraint Core Acquired Ventilator Related Pneumonia Pneumonia For ICCU Improving The Care Of CHF Patients Percent Of Patients Received Weighing Instructions Percent Of CHF Patients On Coumadin CHF Patients With Medication Instructions Patients Discharged on Aspirin/Antiplatelet Meds Patients Treated With Lipid Lowering Agent Percent Of Orders With Dangerous Abbreviations Surgical Wound Infections for High Volume Surgeries Cancer Five Year Survival s Medicine Service Line Pneumonia AMI Beta Blocker At Discharge AHA's Quality Initiative Percentage of Patients Diagnosed With Ischemic Stroke Ventilator Related Receiving tpa Pneumonia For SINU Mortality s Quality Texas Foundation 2008 Page 1 of 12
SCIP Process Bariatric Program Results Medicine Service Line Respiratory System DX With Vent Core Measure Compliance Scores CHF Readmissions Within 31 Days Central Line Related Blood Stream Infections For SINU Nursing Home Physical Restraints ICU Infection Control Patients With Hospital Acquired Pressure Ulcers Stage II+ Women's/Children's Service Line Pregnancy @ Related Conditions Antibiotics Within 1 Hour Of Surgical Incision Lung Cancer Survivor Catheter Related UTI For ICCU Physician Restraint Events Post Acute Influenza Immunizations Hip Functional Status Improvement (Pre OP To One Year Post OP) Home Care Improvement of Patient Transfer Ability All Service Lines DVT Protocol Outcomes PICU VAP Incident Reports Oncology/Behaviora l Health Service Line Calls And Restraints Patient Fall Medication Errors That Did Not Reach The Patient Catheter Related UTI For SINU s Of Seclusion For Behavioral Medicine Patients Childhood Immunizations Surgical ICU Central Line Bloodstream Infections Medicare Data 30 Day Readmissions Overall Hospital/Acquired Skin Breakdown Surgical (Timeout) s of Restraints For Behavioral Medicine Patients Patient Safety CHF Process CHF Mortality MAC Home Health Outcomes System Ventilator Associated Pneumonia s AHRQ Patient Safety Indicators Stroke Care Results Stroke Patient Functional Status Improvement Patient Safety Inpatient Significant Medication Errors Patient Safety Indicators Long term Care Quality Indicators Homecare Quality Compliance Patient Required Patient Falls CARE Overall Score Hospitalists Home Health Significantly Impact Composite Scores Use Of Restraints ALOS Home Health Hospitalists Mitigate Improvement In Pain Costs Of Inpatient Care Home Health Hospital Readmission Open Heart Program Mortality Quality Texas Foundation 2008 Page 2 of 12
Clinic Diabetes Results Diabetes Asthma Disease Appropriate Asthma Med Use Breast Cancer Screening Cervical Cancer Screening Blood Sugar Testing High Risk Cholesterol LDL Control Improvement In Diabetics With LDL > 100 Surgical Infection Prevention Homecare Improvement In Cognitive NICU Chronic Lung Functioning And Disease Percentile Improvement In ADL Ranking Hospital Comparisons In Heart Attack Care, Heart Failure Care And Pneumonia Care Composite Quality Score 7.2 Summarize your organization s KEY PATIENTand other CUSTOMER focused RESULTS for PATIENT/CUSTOMER satisfaction and PATIENT/CUSTOMER perceived VALUE, including PATIENT and other CUSTOMER loyalty. Segment your RESULTS by program or service types or groups, CUSTOMER groups, and market SEGMENTS, as appropriate. Include appropriate comparative data. Percent Satisfied By Core Service Inpatient By Location Inpatient Key Indicators Inpatient/Out Patient Overall Medical Group's Patient Inpatient Rehabilitation Inpatient Patient By Service Line Pediatric By Service Line Patient Overall Inpatient By Service Patient By Patient Group With Nursing With Nursing Courtesy Perception Ranking vs. Top Competitors Perception Ranking By Product Line Patient Inpatient Inpatient Emergency Outpatient Department Ambulatory Outpatients Surgery Quality Texas Foundation 2008 Page 3 of 12
ED By Location ED Key Indicators Clinic By State/Specialty Clinic With Courtesy Mental Health Patient Inpatient Attention To Personal Needs Inpatient Pain Control Long term Care Patient Pain Outpatient Emergency Department Long term Care Dissatisfaction With Discharge Outpatient By Service Patient Dissatisfaction Dissatisfaction By Type ED Patient ED Patient With Nursing ED Patient With Physicians Outpatient Nursing Student Inpatient Would Recommend Outpatient Would Recommend ED Patient Would Recommend Behavioral Medicine Home Health Home Care Staff Did All Possible To Control Pain Did Nursing Staff LifeFlight Respond Quickly Emergency Oncology Patient Department Wait Time Reasonable Acute Care Percent Satisfied Inpatient Priority Patient Index Patient Dissatisfaction By Nurse Patient Requirements Patient Group Staff Sensitivity to Inconvenience Adequate Directions Given About Taking Medications Or Follow up Care Getting Care Needed Physicians And Staff Education By County Customer Loyalty Loyalty Service Recovery Score Target Market Inpatient Family With Patient Pain Control Overall Inpatient Dissatisfaction Improvement of Patient Complaints Grievance s Top of Mind Awareness Of Hospital Systems Patient Loyalty and Referral Home Care Patient Likelihood to Recommend Nursing Care Complaints ED Left Without Loyalty Treatment Average Time to Respond to ER Loyalty Complaints Likeliness To Return Patient Loyalty By Service Employer Top Box, Very Satisfied Loyalty Index Physician Best Overall Hospital Loyalty Food and Nutrition Medical Staff Rating Hospital Preference By Service Type Education Program Cheerfulness of Hospital Outpatient Staff Concern for Privacy Physician with Hospital Administration Involving Medical Staff in Hospital Customer Value Analysis Membership Programs Business with Programs Perception of Quality Quality Texas Foundation 2008 Page 4 of 12
Service Line Preference Grievance Resolve in 30 Days Assessment Of Healthcare Provider 7.3 Summarize your organization s KEY financial and health care marketplace PERFORMANCE RESULTS by PATIENT or other CUSTOMER or market SEGMENTS, as appropriate. Include appropriate comparative data. Growth In Net Revenue Operating Margin Net Revenue Results Uncompensated Care Costs As A Percent Of Total Expenses Profit Margin Days Cash on Hand Total Margin Net Income Hospital Days In Accounts Receivable Profit Margin Return on Assets Average Age Of Property, Plant and Equipment Operating Margin Current Ratio Not For Profit Healthcare Ratings Approved Capital Investment Growth in Equity Billing Cost Per Dollar Earned Not For Profit Healthcare Ratings Distribution Profit Margin By Delivery Mechanism Occupancy Total Revenues Net Patient Revenue Overall Operating Margin Adjusted Fixed Asset Turnover EBITDA Results Days In Accounts Receivable Saving Due to Staffing Services Debt Service Coverage Net Revenues Net Days in Accounts Receivable Operating Revenue and Expense Physician Practice Retail Revenue By Service Volumes Growth Inpatient Market Outpatient Surgery Market Current Ratio of Assets/Liabilities Average Payment Period Professional Liability Insurance Costs Market Results Market By Target Market Segment Days Of Cash On Hand Debt To Capitalization Market Growth Overall Market Inpatient Market Expense Per Adjusted Admission Return on Equity FTE Per Adjusted Return on Total Occupied Bed Assets Inpatient and Outpatient Revenue Case Mix Index Days Cash on Hand Price Increases Vs. Consumer Price Index ER Market Operating Margin Market Value Index Cost Per Adjusted Discharge Ambulatory Surgery Market Operating Margin by Product Line Cash Receipts per Bank Day Utilization Statistics Market Cardiology Product Line Market Orthopedic Product Line Market Outside Primary Service Area Homecare Operating Margin Net Revenue Per Physician Physician Practice Direct Operating Costs Competitive Position Quality Texas Foundation 2008 Page 5 of 12
Physician Office Visit Market Outpatient/Emergen cy Department Market Budget Accountability Report By Service Line Outpatient Imaging Market ED Market Market Open Heart Surgery Market By Region Obstetrics Market Neurology Market Cardiology Market Care Based Cost Cost Per Adjusted Discharge Vs. Average Length Of Stay Market By Service Line Cardiology Market Surgery Market Obstetrics Market Oncology Market Orthopedic Market Bariatric Product Line Procedures Per Year Volume of Cases 7.4 Summarize your organization s KEY workforce focused RESULTS for WORKFORCE ENGAGEMENT and for your WORKFORCE environment. Segment your RESULTS to address the DIVERSITY of your workforce and to address your WORKFORCE groups and SEGMENTS, as appropriate. Include appropriate comparative data. Segmented Turnover Workforce Engagement Indicators Partner Survey Feeling Valued I Speak Highly of Sharp to Others Diversity Demographics Turnover Correlation Between and Patient Human Capital Value Attitude I Am Satisfied With My Employment Retention Rn Turnover RN Retention Diversity of Workforce I Believe My Work Contributes to the Success of Sharp Vacancy s Vacancy s RN Fill Turnover Response Staff Positive Morale Average Acute Length of Stay Paid Hours Per Adjusted Patient Stay Total Outpatient Visit Time Partner Survey Overall Sharp is a Leader in Providing High Quality Services Contribution To Nursing School Education Vacancy s for Respiratory Care Vacancy Needlesticks Patient Correlated to Morale Mammogram Reporting Turnaround Quality Texas Foundation 2008 Page 6 of 12
Worklife Balance Nursing RN Staffed s Commitment to Nursing Mentor Education Program Co pendency s by Training By Job Class Ethnicity Effectiveness Vacancy Increase in Compensation Benefit Spending Retention by Job Internal Promotion Type Performance Appraisal Timely Completion Ethic Diversity Treated Fairly Trust Index Timely Performance Appraisal Annual Retention By Job Class Turnover Workforce Vacancy s Hired by Internal Referral Retention Results Availability of Inventory Training Hours Per FTE Job Growth Turnover Retention Turnover Invoice Error With Training Recognition and Rewards Workplace Health and Safety Culture of Patient Safety Livewell Incentive Plan Timely Performance Appraisals Training Hours per FTE Investment in Development Tuition Assistance Feedback for Improvement Overall Leadership Decisions Temporary Help Expenses Performance Appraisal Scores Internal Referrals Training Hours per FTE Investment in Development Nursing Education Hours Awarded Composite Dissatisfaction Rn Vacancy Purchasing Savings Improvement Ideas Recognition Certificates Late Evaluations ROI on Training Needlesticks Days Sales Outstanding Electronic Applicant Tracking Information Systems Reliability and Dependability Claim Transmission Volumes Insurance Cash Collections Net Account Receivable Days Lost Time Injuries Safe Environment Training Expenditure By Termination Due to Absenteeism Women and Minorities in Managerial and Professional Positions with Benefits Survey Segmentation Ideas for Excellence s with Benefits with Pay Job Mobility Segmented by Shift by Department by Segment JCAHO Survey Scores OSHA Reportable Incidents Charity Goals and Charity Care Provided Quality Texas Foundation 2008 Page 7 of 12
Workers Correlated Patient Compensation Claims Outcomes Cost of Lost Time To Worker's Compensation Volunteer Services I Feel Safe in my Work Environment Work Environment Factors with Recognition Sharps Injuries OSHA Experience Codification Number OSHA Injuries Sprains and Strains 7.5 Summarize your organization s KEY operational PERFORMANCE RESULTS that contribute to the improvement of organizational effectiveness, including your organization s readiness for emergencies. Segment your RESULTS by HEALTH CARE service types and groups, by PROCESSES and locations, and by market SEGMENTS, as appropriate. Include appropriate comparative data. Average Length of Stay Days to Third Next Available Appointment Work Systems Results Overall Physician Length of Stay Vs. Case Mix Index Productivity FTE Per CMI AOB Medicare Length of Stay Occupancy All Payer Length of Stay Medicare Length of Stay Admitting Wait Time Supply Fill Laboratory Precision Cafeteria Customer Survey NOT AVAILABLE Emergency Administrative General Expense Administrative Expense Ratio Provider Survey Average Lines Per Order Monthly Days Sales Outstanding Labor Per CMI Adjusted Discharge Diversion s Environmental Services Productivity Vs. Room Cleanliness ER Door to MD Time Cardiology Worked Antibiotics within 4 Hours Per Procedure Hours Ventilator Associated Pneumonia Urinary Tract Infections Hip Orthoclastic Infection Radiology Turnaround Time Pharmacy Stock out Nursing Student First Time Pass Patient for Food Service Patient Room Work Orders Information Systems Enterprise System Availability Critical Imaging Equipment Uptime Invoicing Accuracy Cardiac Pacemaker Implant Handwashing Central Line Infections Research Grant Dollars Received Information Services Helpdesk Calls Quality Texas Foundation 2008 Page 8 of 12
Critical Test Result TAT E Commerce Automated, Electronic Orders Information Systems Response Times Verbal Order Read Back Hospital Acquired Decubitus Key Supplier Performance Website Usage Days in Accounts Receivable Hip and Knee Implant Costs Gross Charges Transcription Quality Denied by Payers Dollars Saved From Out of Network Biomed Efficiencies Project Marketing Turnaround Time Valet Parking Phone Interpretative Savings Performance on Disaster Drill AMI Smoking Sensation HF LVF Assessment Supplier Report cards Stroke Education Days Sales Outstanding Health Efficiency Laboratory Critical Value Statistics IT User Survey Energy Annual Urgent Care Door to Savings Doctor Time Call Center Referral Pharmacy Purchasing Statistics Information Systems Down Time Radiology Report Procedures to Dictation Wait Time for Radiology Patients Timeliness of History and Physical Completed within 24 Hours Patient with Response Time Arrival to EKG Cycle Time Unplanned Returns Radiology Report MICU Vent Device to ED within 72 Doctors One call Turnaround Hours Volume Facility Operations with Work order Wait Time in Completion Hospitalist Discharges Registration Physician Information on the Cash Collection on Laundry Rewash Requirements Day of Surgery Target Ambassador Services Response Time Awards Supplier Report card Cost Per Hire Breast Case Center Arrival to Registration Time Physician Service Center Contract Cost Savings Inventory Turns Inventory Turns Helpdesk Cycle Time Preventive Total Materials/Total Maintenance Fill s Hospital Expense Completion with Supply Contract Ease of Scheduling Savings Internal Fill Appointments Awards and Recognition Linen Fill Radiology Cycle Time Information System Admitting Frontend Availability Collections Inpatient Tests/Discharge High Admitting CMI Hospitals Registration Accuracy Dictation Compliance Net Days in Accounts Radiology Receivable Turnaround Times Laboratory Annual Early Bird Results Awards and Recognitions Productivity by Pay Period Laboratory Productivity Food Service Delivery Timeliness Primary Order Mean Cycle Time Energy Volumes Physician Partner Performance Quality Texas Foundation 2008 Page 9 of 12
Patient Financial Services Call Center Stats Impatient with Nursing Staff Network Uptime Gross Days in AR IT First Call Resolution Medical Record Delinquency Days to Final Bill Segmented by Service Days in Accounts Receivable Mental Health Patient Hip/Joint VTE Prophylaxis by Gender Equitable Care Transcription Turnaround Time Number of Concierge Requests Patient Cleanliness Rating with Security 7.6 Summarize your organization s KEY GOVERNANCE and SENIOR LEADERSHIP RESULTS, including evidence of strategic plan accomplishments, ETHICAL BEHAVIOR, fiscal accountability, legal compliance, social responsibility, and organizational citizenship. Segment your RESULTS by organizational units, as appropriate. Include appropriate comparative data. Goal Achievement Dashboard IHN Integration Composite Score Growth Statistics Admissions from ED Inpatient Admission Growth Percentage Cumulative Growth Percentage Report Card Performance Capital Spending Ratio Access to Services and Market Malpractice Claims EEOC Board of Director's Self Assessment BOD Volunteer Hours Survey Leadership and Social Responsibility Waste Volumes Donations to Local and International Nonprofits Public Responsibility and Ethics Frequency and Severity/Average Coverage Year Perception of Safety Governance and Social Responsibility Corporate Compliance Response to Issues Baldridge Assessment Scores Board Member Survey Self Pay Revenue Sponsorships Education Activity Service HealthSource Calls NOT AVAILABLE Quality Texas Foundation 2008 Page 10 of 12
Board Certified Physicians Corporate Compliance in Ethics Program Effectiveness Charity Care as Percent of Gross Patient Revenue Benefits Dollars Donated to Organizations Charitable Giving By s Annual Sports Physicals and Followups Average Charge per Discharge Evaluation of Sharp's Culture of Compliance Grants and Appropriations Funded Hospital Program Attendance Charity Care Dollars Education Heart Risk Screening Partner Perception of BOD Assessment Results Ethical Behavior Accreditation Sanctions Due to HIPAA Violations Medication Assistance Program Wellness Services Contacts Health Services Board Self Library Document Assessment Results JCAHO Scores Delivery Summary of Financial United Way Audits Benefits Donations Summary of Regulatory Audits Sponsorships Use of Volunteers Volunteer Hours Awards and Recognition Licensure and Compliance Pounds of Infectious Waste per Licensed Bed per Day Charity Care Charitable Giving by Mercy and Partners Number of Audits Conducted by Internal Audit Teams Outreach Safety Education Compliance Tobacco Use Donation of Hours to Programs Nurse Link Financial Support of Vulnerable Population, Heath Research, and the Broader Contracts by County Total Economic Value of Benefits Provided Quality Texas Foundation 2008 Page 11 of 12
Image Recognition and Awards Awards and Honors Quality Texas Foundation 2008 Page 12 of 12