New Data Collection Methods And Control Charts

Cook County Health Board of Directors
Quality & Patient Safety Steering Committee
​January 18, 2024 - No meeting this month - report based on dashboard slides

In 2023, data was reported in monthly increments.  In 2024 the committee will look at most of the data on rolling 12-months increments to better quantify improvements. Not all data will have this format to start with. 

In 2024 control charts have been added for performance monitoring data for many items. Control charts are visual depictions of quantitative data. They can be used for common variation monitoring or new process parameters (good/bad).  The new areas of focus are listed below:

Stroger Hospital 
Patient Experience
    Improve % Top Box for Communication with Nursing Domain
    Improve HCAHPS Survey Response Return percent
Clinical Outcomes
    Reduce CLABSI,( central line-associated bloodstream infection ) and 
   CAUTI (Catheter-Associated Urinary Tract Infection) & CDIF Volume of occurrences    
Reduce PSI - Patient Safety Indicator PSI12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis volume of occurrences
Readmissions
     Reduce House wide Readmissions all Payors-including patients admitted elsewhere
Throughput
     Reduce timeline of Inpatient Ordered to physician verified (Diagnostic Radiology Orders)
      Improve GMLOS (geo-metric mean length of stay) variance
Clinical Documentation
     Increase Overall Medical & Surgical CMI 

Provident Hospital 
Patient Experience
     Improve % Top Box for Communication with Nursing Domain
     Improve HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)      
     Survey Return percent 
Clinical Outcomes
     Improve SEP-1 (Severe Sepsis and Septic Shock Management Bundle) Compliance Rate
     Improve HH (hand hygiene) Compliance and coach clinicians where we are not meeting the  
     compliance.
Throughput 
     Improve LWBS ( left without being seen) Rate

Observer - Lisa Slankard