skmch&rc lahore · 2020. 1. 17. · ipd1 ipd2a ipd2b ipd3 icu or chemo nopd / ear patient...
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SKMCH&RC Lahore
Clinical Performance & Cancer Centre Dashboard3rd Quarter 2019
100% 100% 99% 100%100%97%
100% 100% 100% 100%
0%
20%
40%
60%
80%
100%
IPD1 IPD2A IPD2B IPD3 ICU OR CHEMO NOPD / EAR
Patient Identification – Inpatient Departments
2018
Q3 2019
International Patient Safety Goals
97% 99%
0%
20%
40%
60%
80%
100%
2018 Q3 2019
Patient Identification - Outpatient
Chemo – Chemotherapy Department, EAR – Emergency Assessment Room , ICU – Intensive Care Unit, IPD – In-patient Department,NOPD – Nursing Out-patient Department, OR – Operation Rooms
International Patient Safety Goals
2
0
3
12
1
29
2
0 0 0
3
1 10 0 0 0 0 0
0
10
20
30
IPD - I IPD - II A IPD - II B IPD III ICU OR CHEMO NOPD
Falls Reported – Inpatient Departments
2017
2018
Q3 2019
90%86% 88%
92%92%87%
96% 96%96% 98% 100%97%
0%
20%
40%
60%
80%
100%
IPD I IPD II A IPD II B IPD III
Fall assessment – Inpatient Departments
Q1 2019
Q2 2019
Q3 2019
100% 98% 100%
0%
20%
40%
60%
80%
100%
2017 2018 Q3 2019
Fall assessment - Outpatient
Chemo – Chemotherapy Department, EAR – Emergency Assessment Room , ICU – Intensive Care Unit, IPD – In-patient Department,NOPD – Nursing Out-patient Department, OR – Operation Rooms
74%
67%
80%76%
0%
25%
50%
75%
2016 2017 2018 Q3 2019
Hand Hygiene Compliance
Doctors
Nurses
HCAs
Others
87%82%
85%93%
85% 81% 85% 90%
81% 78% 85% 91%
99% 100%
0%
40%
80%
2018 Q3 2019
Timeout Compliance
Endoscopy
100% 100%
99% 99%
International Patient Safety Goals
OR
Radiology
HCA – Healthcare Assistant, OR – Operation Rooms
98% 100%
90%100%
92% 98%
98% 98%
96%100%
0%
15%
30%
45%
60%
75%
90%
2018 Q3 2019
Patient Handover Compliance
IPD 1
IPD 2B
IPD 3
NOPD/EAR
IPD 2A
ICU
92% 100%
100% 100%
International Patient Safety Goals
0.08
0.1
0.0
0.1
0
0.1
0.2
2018 Q3 2019
High Alert Medications & Conc. ElectrolytesErrors with harm per 10,000 items
HAM
ConcentratedElectrolytes
Chemo
35
19
2 1.30
10
20
30
40
2018 Q3 2019
High Alert Medications & Conc. ElectrolytesME NM per 10,000 items
HAM
ConcentratedElectrolytes
Chemo – Chemotherapy Department, EAR – Emergency Assessment Room , ICU – Intensive Care Unit, IPD – In-patient Department, NOPD – Nursing Out-patient Department
90% 92% 91%
10% 8% 9%
0%
20%
40%
60%
80%
100%
2017 2018 Q3 2019
Delayed Reporting
In-Time Reporting
100%
73.3%
100%
0%
26.7%
0%
0%
20%
40%
60%
80%
100%
2017 2018 Q3 2019
Delayed Reporting
In-Time Reporting99.8% 99.6% 98.7%
0.2% 0.4% 1.3%
0%
20%
40%
60%
80%
100%
2017 2018 Q3 2019
Delayed Reporting
In-Time Reporting
Nuclear Medicine CompliancePathology Compliance
Radiology Compliance
Critical Alerts
Medication Errors & Adverse Events
412
131
57
0
50
100
150
2018 Q3 2019
Medication ErrorsAverage items dispensed
2019= 127,850
Medication Errors Near Misses
40
25
15
26
1412
0
10
20
30
40
50
Total ADRs Reported Type A ADRs Type B ADRs
Adverse Drug Events
2018
Q3 2019
ADR – Adverse Drug Reported
Infection Control Statistics
0.3
2.92.6
0.4
2.5
1.5
0.0
1.11.6
0.0 0.0 0.00.0
2.0
4.0
6.0
CAUTI CLABSI VAP
2016
2017
2018
Q3 2019
SKMCH Infection Rates
CAUTI – Catheter Associated Urinary Tract Infection, CLABSI – Central Line Associated Blood Stream Infection, NHSN – National Healthcare Safety Network, VAP – Ventilator Associated Pneumonia
3.3
2.0
3.34.19
4.82
12.2
0.0 0.0 0.00
5
10
15
CAUTI CLABSI VAP
SKMCH Infection Rates Vs NHSN Rates
NHSN Ratio
INICC Rates
SKM Infection Rates/1000 DD.
88%
60%70%
98.3%
12%
40%30%
1.7%
0%
20%
40%
60%
80%
100%
2016 2017 2018 Q3 2019
Radiation Completion Delayed
Radiation Completed In Time
Radiation Oncology Activity
1110
0
5
10
15
2018 Q3 2019
Blood Transfusion Reaction
Hospital wide Indicators
88%
74%
99%
91%
100% 99%
0%
20%
40%
60%
80%
100%
Pain Assessment Pain Reassessment
Pain Management
2017
2018
Q3 2019
12
21
18
8
0
3 32
1
5
01 1
0 0
2
00
5
10
15
20
IPD - I IPD - II A IPD - II B IPD III ICU NOPD
Pressure Ulcers
2017
2018
Q3 2019
ICU – Intensive Care Unit, IPD – In-patient, NOPD – Nursing Out-patient Department
Clinical Performance Indicators
0.1
0.4
0.5
0.2
0.0
0.3
0.4
0.2
0.1
0.2
0.3
0.2
0.0 0.0
0.2 0.2
0
0.2
0.4
0.6
0.8
InternalMedicine
MedicalOncology
PediatricOncology
SurgicalOncology
Pe
rce
nta
geRe-Admissions Within 7 Days
Specialty wise
2016
2017
2018
Q3 2019
0.3 0.4
0.9
2.8
0.70.8
2.2
0.7
4.5
1.7
3.5
4.5
0.8
1.4
0.5
2.0
0.7
2.3
0.0
1.0
2.0
3.0
4.0
5.0
6.0
Surgeon 1 Surgeon 2 Surgeon 3 Surgeon 4 Surgeon 5 Surgeon 6 Surgeon 7 Surgeon 8 Surgeon 9 Surgeon 10 Surgeon 11 Surgeon 12
Pe
rce
nta
ge
Re-Admissions Within 30 DaysSurgical Oncology
2017
2018
Q2 2019
Q3 2019
Clinical Performance Indicators
1.7
0.30.6 0.5 0.5
1.9
1.2
0.70.3
2.2
0.2
3.2
1.5
2.9
0.50.9 1.0
2.9
0.5
3.0
1.0
3.7
6.9
1.3
0.5
3.3 3.3
0.8 0.9
0.0
2.0
4.0
6.0
8.0
10.0
Surgeon 1 Surgeon 2 Surgeon 3 Surgeon 4 Surgeon 5 Surgeon 6 Surgeon 7 Surgeon 8 Surgeon 9 Surgeon 10
Pe
rce
nta
ge
Multiple Surgical Procedures in One Admission
2016
2017
2018
Q3 2019
97% 94% 98% 99%
3% 6% 2% 1%
0%
20%
40%
60%
80%
100%
2016 2017 2018 Q3 2019
Delayed Reporting – Radiology
Delayed Reporting
In time Reporting
Clinical Performance Indicators
98% 98% 98% 99%
2% 2% 2% 1%
0%
20%
40%
60%
80%
100%
2016 2017 2018 Q3 2019
Delayed Reporting – Pathology
Delayed Reporting
In time Reporting
Chemotherapy Activity
102218549
78098502
3575
24332580
3128
0
5000
10000
15000
2016 2017 2018 Q3 2019
Patient Activity
Pediatrics
Adults
13795
1098210389
11630
11575
80
800 726 614
9719
175646
300 143
8797
33
888
128 69474
9752
7
1291
63 10507
0
4000
8000
12000
Chemotherapy Antibiotic Central Line Dressing Hydration Blood Transfusion IT
Main areas of Activity
2016
2017
2018
Q3 2019
Outpatient Parental Antibiotic Therapy Activity
1168687 936 980
4586
41994320
5167
0
1500
3000
4500
6000
7500
2016 2017 2018 Q3 2019
Number of Patients’ Visits
Pediatrics
Adults
5754
50665256
6147
620 411 489 682
1795 20222252
3580
0
1500
3000
4500
2016 2017 2018 Q3 2019
Number of Patients
Pediatrics
Adults
4262
2470
24322415
Average Length of Stay – Specialty Wise
4.2
5.5
2.5
3.1
2.4
4.0
6.2
2.0
3.0
2.3
3.9
6.0
2.62.9
2.5
4.2
5.1
2.52.8
2.4
0
1
2
3
4
5
6
7
Internal Medicine Medical Oncology Nuclear Medicine Pediatric Oncology Surgical Oncology
Day
s
Inpatients
2016
2017
2018
Q3 2019
No. of AdmissionsInternal Medicine: 714Medical Oncology: 813Nuclear Medicine: 46Pediatric Oncology: 1063Surgical Oncology: 1961
3:54
3:233:41
3:203:01
3:17
4:20
2:44
3:373:41
2:48
3:14
0:00
1:12
2:24
3:36
4:48
Internal Medicine Pediatric Oncology Overall Average
EAR(Hrs:Mins)
2016
2017
2018
Q3 2019
No. of Admissions:Internal Medicine: 4882Pediatric Oncology: 1508
0.8 0.8
0.5
0.3
0.6
0.7
0.5 0.5
1.1
0.6
0.4
0.7
1.1
0.3
0.2
0.7
0
0.5
1
1.5
Internal Medicine Medical Oncology Pediatric Oncology Surgical Oncology
Day
s
ICU
2016
2017
2018
Q3 2019
Average LOS – Bed Occupancy
5 5
4
2
6
4
5
2
4 4
3
4
0
2
4
6
8
Internal Medicine Medical Oncology Pediatric Oncology Surgical Oncology
Day
s
Average Ventilated Patients Length of stay - Specialty wise
Q3 2018
Q4 2018
Q3 2019
81
66
7980
59
7882
63
8184
60
82
0
20
40
60
80
100
IPD ICU Overall
Pe
rce
nta
ge
Bed Occupancy
2016
2017
2018
Q3 2019
ICU Capacity: 15IPD Capacity: 180
IPD – In-patient Department, ICU – Intensive Care Unit
100%95%
90% 91%95%93% 95%
98% 99%94%
99%100% 100%97% 97% 100%
0%
20%
40%
60%
80%
100%
1 2 3 4 5Levels
Patients Seen within Defined Waiting Times – ADULTS
2016
2017
2018
Q3 2019
Emergency Assessment Room Statistics
Standard Waiting Times (minutes)ESI Level 1: Immediately 1(30)ESI Level 2 : 4(911)ESI Level 3 : 53 (2614)ESI Level 4 : 16 (1195)
ESI Level 5 : (25)
6322
4952 4802
6257
0
3500
7000
2016 2017 2018 Q3 2019
90%
81%
98% 99% 99% 98%100% 98% 99% 99%100% 100% 100% 100% 100% 100%
0%
20%
40%
60%
80%
100%
6 5 4 3 2 1 0
Levels
Patients Seen within Defined Waiting Times – Pediatrics
2017
2018
Q3 2019
PEWS Index Standard Waiting Times (minutes)Level 4-9: Urgent Evaluation(8) Level 3: (190) Level 2: (410)Level 0-1: (874)
Complaints – Clinical Departments
13
41
1 2 3
14
27
0
57
17
46
24 4
23
17
128
6
0
10
20
30
40
50
Delay in Services Quality of Services Resource Availability Issue Communication Equipment Related Issue
Established Clinical Complaints by Service Category
2016
2017
2018
Q3 2019
335
249 239267
0
100
200
300
400
2016 2017 2018 Q3 2019
Total Number of Complaints285 285
0
100
200
300
Q1 2019 Q2 2019
Complaints – Clinical Departments
16
8
15
12
8
16
1213
16
12
32
2322
31
19
44
2524
2220
0
10
20
30
40
50
Pathology Medical Oncology Surgical Oncology Radaition Internal Medicine
Established Clinical Complaints by Department
2016
2017
2018
Q3 2019
Cancer Specific Indicators
90% 91%99% 98% 97%
0%
20%
40%
60%
80%
100%
Benchmark 2016 2017 2018 Q3 2019
Histopathology Reports Completeness
Benchmark
2016
2017
2018
Q3 2019
3.60%
0.6% 0.6% 0.6%
0.15%
0.0%
1.0%
2.0%
3.0%
4.0%
Benchmark 2016 2017 2018 Q3 2019
Cancer Patient Readmission (Surgery)
Benchmark
2016
2017
2018
Q3 2019
Cancer Specific Indicators
465
45
87 79
132
0
100
200
300
400
500
Benchmark 2016 2017 2018 Q3 2019
Chemotherapy Patients EAR Admissions
Benchmark
2016
2017
2018
Q3 2019
233
18 22 24
53
0
50
100
150
200
250
Benchmark 2016 2017 2018 Q3 2019
Chemotherapy Patient Inpatient Admission
Benchmark
2016
2017
2018
Q3 2019
6%
7%
6%
5%
7%
0%
2%
4%
6%
8%
10%
Benchmark 2016 2017 2018 Q3 2019
Proportion receiving chemotherapy in the last 14 days of life
Benchmark
2016
2017
2018
Q3 201910%
51%
40%36%
34%
0%
20%
40%
60%
Benchmark 2016 2017 2018 Q3 2019
Proportion admitted to the ICU in the last 30 days of life
Benchmark
2016
2017
2018
Q3 2019
EAR – Emergency Assessment Room , ICU – Intensive Care Unit
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