Quality and Safety Measures

The Clinical Quality Scorecard measures performance at each Methodist Le Bonheur Healthcare facility. This report helps us improve performance on specific indicated conditions and treatments in a timely fashion.

Most performance indicators are based on definitions provided by CMS and JCAHO. Indicators such as usage of care tracks are defined internally by MLH policy.

The report is based on a review of our documentation of care.

Measurable Indicators:

• Acute Myocardial Infarction
• Congestive Heart Failure
• Pneumonia
• Hip and Knee Replacement
• Stroke
• CABG
• Med errors with harm
• Falls with harm
• Restraint days
• Nosocomial infection rates
• LOS (facility-specific DRG)
• Avoidable days
• Patient complaints
• Needle sticks
• Back injury

Updated CMS Indicator Information-New Inclusion/Exclusion Criteria, Beginning with October 1, 2007 discharges.

Updated CMS Indicator Information

Posted by Miriam Elmore
10/01/2007