Académique Documents
Professionnel Documents
Culture Documents
Days in A/R
D is char ge S ummar y T imelin ess R at e
80%
70%
80 60%
New 50%
70 Dic- 40%
30%
20%
60 10%
0%
T m
i e ly
S u b ms
io n o C
f h a rg e s
1 2 3 4 5 6 7 8 9 10 11 12
50 Clean Claims
1 2 0%
40 1 00%
8 0%
30 6 0%
4 0%
20 2 0%
0%
1 2 3 4 5 6 7 8 9 1 0 1 1 1 2
10 C h a rtC o d n
i g R a te
Timeliness of Coding
0 120%
1 2 3 4 5 6 7 8 9 10 11 Coding
12 100%
Training 80%
Tm
i e lin e s s B iln g R a t e f o r S e c o n d a r y C a
l im s 60%
40%
T im e lin e s s B illin g R a te o n P rim a ry C la im s
Timely Billing for Primary Claims Timely Billing for Secondary Claims 20%
120%
1 2 0%
0%
1 2 3 4 5 6 7 8 9 10 11 12
100%
1 00%
80%
New Sys- 8 0%
100%
90%
40%
bills into 60%
50%
the secon-4 0%
40%
bucket 2 0% 20%
10%
0%
1 2 3 4 5 6 7 8 9 10 11 12 0%
0% 1 2 3 4 5 6 7 8 9 10 11 12
1 2 3 4 5 6 7 8 9 10 11 12
90%
the self-pay billing bucket
80%
70%
60%
50%
40%
30%
20%
The Efforts of the “Timely Money” Team
10 %
0%
1 2 3 4 5 6 7 8 9 10 11 12
Thanks for a Job Well Done!
B o a r d R e p o r t P a g e 2
K e y O p p o r t u n i t i e s f o r i m p r o v e m e n t
r
r
r
ry
y
er
ch
be
ne
be
ril
be
ly
ay
s
ar
ua
ob
gu
Ap
Ju
ar
m
Ju
em
m
M
nu
Au
ct
ve
M
ce
Ja
pt
Fe
No
De
Se nursing and pharmacy staff have done a great
Transcription Errors Omi ssi on Er r or s
job in making our QI goal of reduced medica-
120.00%
100.00%
70.00%
tion errors happen.
60.00%
80.00% 50.00%
40.00%
60.00% 30.00%
40.00% 20.00%
10.00%
20.00%
0.00%
0.00%
De er
ry
Fe y
ne
r
rch
Oc r
No er
ril
ly
t
y
be
s
ar
Ma
b
ua
Ap
Ju
mb
gu
b
Ju
m
nu
Ma
m
to
Au
br
ve
pte
ce
Ja
Se
ce er
O ber
r
M y
Fe ary
ve er
ch
pt st
be
ne
ril
A ly
ay
r
De mb
ua
No tob
Se ugu
Ap
Ju
em
ar
m
Ju
M
nu
br
c
Ja
K e y P a t i e n t S a t i s f a c t i o n F i n d i n g s
Would you recommend this hospital to family and friends?
Woul d Y ou R e c omme nd T hi s H os pi t a l t o Fr i e nds a nd Fa mi l y
120%
100%
In April we implemented a
major guest relations program
80%
and service recovery program.
This last quarter we have seen
60%
Surge in
agency staff
a significant improvement and
40%
due to nursing stabilization in the question on
20% resignations our patient satisfaction survey.
The stabilization of staff has
0%
1 2 3 4 5 6 7 8 9 10 11 12
helped.
101%
In April we implemented a
100%
major guest relations program
99%
and service recovery program.
98%
Over the past two quarters we
97%
have seen an improvement an
96%
stabilization in the area. The
95%
94%
stabilization of staff has
93%
helped.
92%
91%
1 2 3 4 5 6 7 8 9 10 11 12
Areas of Priority
Did you see or experience anything that you felt could be unsafe? If yes, what was it?
I had two medication errors while I was in the hospital. It would seem to me that this would be less likely to
occur if I had had the same nurse giving me my medications. While I saw the same nurses every day, every
day I had a different nurse giving me my medications,
The locks on my bed did not work well and it would move when I would get in and out unless I was careful.
The water in my bathroom was really hot. If an old person were to be in that room I bet it would be easy for
them to make the mistake of not testing the water and burning themselves.
If there is something we could have done to make your experience better, what was it?
It would have helped me to sleep if the nurses could have been quieter at the desk at night.
The space in which I was receiving physical therapy was so small that patients were bumping into one another.
The woman in the bed next to me liked to watch TV until the early hours of the morning and I could not sleep. The
hospital should have rules about how late the TVs can stay on.
My family complained that the parking lot was dark because so many light bulbs were blown out and made them feel
unsafe leaving the hospital at night.
P a g e 5 S u n s h i n e M e m o r ia l
P a t i e n t S a t i s f a c t i o n
-2 -1 Current Quality Improvement
Month Month Opportunity
Admission
3. Efficiency of admission process 4.3 4.4 4.2 Comments about numerous telephone inter-
ruption for staff during admission process
Room
5. Courtesy of staff who came into your room 4.9 4.9 4.9
Meals
1. Quality of food 4.1 4.4 4.3 No specific complaints but quality of food
consistently scores poorly. Dietary currently
conducting patient interviews to determine
plan
2. Temperature of food 4.5 4.6 4.4 To be addressed as part of above plan. Pri-
mary comments associated with breakfast
3. Assistance you received with your meals 4.9 4.7 4.9
4. Explanation you received if you had a special diet 4.8 4.9 4.9
Staff
4. How well staff kept you informed 4.3 4.7 4.65 No specific complaints. Included on walking
round assessments to determine what could
be done to improve this score
5. Teamwork displayed by the staff who cared for you 4.7 4.7 4.95
6. Timeliness of response for pain medication 4.3 4.1 4.3 Nursing, pharmacy and medical staff working
on improvement plan.
Physician
1. Time the physician spent with you 4.5 4.7 4.65 Referred to medical staff
2. Physician’s concern for your questions and worries 4.2 4.4 4.63 Referred to medical staff
3. Friendliness and courtesy of physicians involved in your care 4.4 4.4 4.5 Referred to medical staff
5. Physician willingness to listen to information you have to share about your 4.3 4.4 4.35 Referred to medical staff
condition or illness
Discharge
1. Extent to which you felt ready for discharge 4.75 4.8 4.85
2. Involvement of your family in discharge planning 4.7 4.65 4.75 Referred to nursing for plan development
Board Report December 2007
Q u a l i t y A s s u r a n c e R e a d i n e s s
Activities
Billing Days in Receivable are at 37 days. Nine months ago we were at 78 days. Opportunities for improvement
continue to be addressed. The goal is 30 days.
Brentwood Clinic
Cardiopulmonary
Central Supply Spore strips indicated sterilization problems with primary sterilizer. New parts installed. Repaired within
8 days. Out-sourced sterilization to Friendly Hospital until fixed.
Dietary Water temperature on dishwasher does not reach required temperatures due to age. Implemented plan for
chemical sanitization that meets state guidelines. New dishwasher is in capital budget for next year.
Emergency Room Potential EMTALA problem with confusion between ER and OPs identified on State survey. Policies and
procedures established to address issue.
Housekeeping
Human Resources
Infection Control
Laboratory Laboratory did not pass proficiency testing in two areas. Corrective action plans submitted to the state
and accepted. Will monitor closely until resolution is certain.
Nursing –Acute State deficiency for sterile technique in the preparation of IV medications and leaving medication unat-
tended in an unlocked medication cart in patient care areas that could be accessed by patients. QI plans in
place.
Obstetrics
Oncology
Maintenance Mixing valve failed on primary water line making water temperature control difficult. New value in-
stalled with 48 hours.
Material Management
Nuclear Medicine
Pharmacy
Radiology
Rosewood Clinic Sample drugs are not being managed according to procedure. QI plan in place and in compliance within 3
days. Fire extinguishers not checked last month. QI plan in place. Checked immediately and placed on
Maintenance checklist.
Rehab Services
Swing Bed
Safety Numerous firewall penetrations identified by the Fire Marshall. QI plan in place to have repaired within
30 day.
Surgical Services Physician #012 did not have H&P done prior to start of cases for 3 cases last month. Addressed through
physician peer review. A new checklist has been developed and the charts will be screen before the start
of all cases and cases won’t start without H&Ps.
Ultrasound
Utilization Review
Hospital Compare
Submissions
Trauma Registry
Submissions