Assignment: Dashboard Analysis and Nursing Plan

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Nurse-Sensitive Quality Indicator Dashboard - Adams 5 (Inpatient Rehab Unit)
Time Period Q3FY05 Q4FY05 Q1FY06 Q2FY06 Q3FY06 Q4FY06 Q1FY07 Q2FY09 Q3 FY09 Q4 FY09 Q1 FY10
Description Mean Target^ Actual Var Mean Target Actual Var Mean Target^ Actual Var Mean Target^ Actual Var Mean Target^ Actual Var Mean Target^ Actual Var Mean Target^ Actual Var Mean Target^ Actual Var Mean Target^ Actual Var Mean Target^ Actual Var Mean Target^ Actual Var
NDNQI Data
NHPPD^^ 7.65 8.52 6.39 -2.13 7.82 8.78 7.06 -1.72 8.08 9.10 6.41 -2.69 8.13 9.07 6.54 -2.53 7.97 6.51 6.31 -0.20 8.09 6.51 7.03 0.52 8.15 6.69 7.07 0.38 8.15 6.69 6.56 0.13 7.95 6.69 6.59 0.10 8.18 6.69 6.23 0.46 8.27 7.19 7.23 -0.04
RN Care Hrs 53.31 61.47 59.46 -2.01 53.3 61.09 56.96 -4.13 53.48 60.56 59.20 -1.36 53.84 60.89 56.87 -4.02 54.82 62.09 56.01 -6.08 54.05 61.08 59.47 -1.61 54.48 62.42 58.42 -4.00 54.86 61.86 58.71 3.15 55.49 61.86 55.90 5.96 54.93 61.86 56.59 5.27 54.81 61.86 54.07 7.79
%AGNCYHR 1.76 0.00 0.31 0.31 1.8 0.00 0.06 0.06 1.83 0.00 3.05 3.05 1.85 0.00 6.01 6.01 1.85 0.00 6.89 6.89 1.76 0.00 6.58 6.58 1.92 0.00 0.00 0.00 1.99 0.00 0.84 -0.84 2.32 0.00 0.84 -0.84 2.12 0.00 0.08 -0.08 2.8 0.00 0.00 0.00
%PRSSULC 15.28 3.70 23.81 20.11 15.18 5.26 15.00 12.85 12.85 3.23 17.39 14.16 14.39 4.17 44.44 40.27 16.11 4.35 22.22 17.87 15.41 4.17 0.00 -4.17 14.65 0.00 23.53 23.53 16.47 2.84 20.00 -17.16 14.15 2.84 10.53 -7.69 13.37 2.84 0.00 2.84 12.41 2.84 8.70 -5.86
%AQPRULC 7.46 0.00 4.76 4.76 6.68 0.00 15.00 15.00 5.01 0.00 8.70 8.70 6.07 0.00 33.33 33.33 6.65 0.00 5.56 5.56 5.84 0.00 0.00 0.00 5.64 0.00 17.65 17.65 7.73 0.00 0.00 0.00 6.58 0.00 5.26 -5.26 6.58 0.00 0.00 0.00 6.15 0.00 4.35 -4.35
%PRSRSKA 54.74 100.00 100.00 0.00 59.02 100.00 95.00 -5.00 56.68 100.00 78.26 -21.74 63.46 100.00 94.44 -5.56 63.9 100.00 100.00 0.00 61.48 100.00 100.00 0.00 65.72 100.00 100.00 0.00 67.77 100.00 100.00 0.00 65.2 100.00 100.00 0.00 68.51 100.00 100.00 0.00 68.79 100.00 60.87 -39.13
TOTFALLS 7.35 3.00 5.71 2.71 7.71 3.45 10.11 6.66 7.35 2.93 24.37 21.44 7.32 2.86 8.84 5.98 7.56 3.22 8.64 5.42 7.73 3.17 4.28 1.11 7.46 3.03 2.40 -0.63 7.46 3.14 6.96 -3.82 7.68 3.14 0.00 3.14 7.31 3.14 5.97 -2.83 7.38 3.14 9.19 -6.05
%RSK&PROT 91.11 100.00 100.00 0.00 90.35 100.00 90.00 -10.00 90.12 100.00 66.67 -33.33 92.27 100.00 81.82 -18.18 92 100.00 80.00 -20.00 90.91 100.00 80.00 -20.00 92.01 100.00 66.67 -33.33 88.18 100.00 100.00 0.00 78.86 100.00 100.00 0.00 81.58 100.00 80.00 -20.00 91.09 100.00 100.00 0.00
%BSN 31.44 42.86 31.25 -11.61 32.98 44.44 21.43 -23.01 32.97 44.44 23.08 -21.36 34.03 44.64 36.36 -8.28 33.42 46.41 50.00 3.59 32.31 45.45 57.14 11.69 32.11 43.75 53.33 9.58 33.42 45.20 46.67 1.47 32.07 45.20 47.00 1.80 33.36 45.20 53.33 8.13 33.19 45.20 62.50 17.30
% CERT 12.72 20.00 31.25 11.25 14.34 22.73 0.00 -22.73 15.33 24.00 15.38 -8.62 16.02 25.00 18.18 -6.82 14.92 25.00 14.29 -10.71 15.78 23.53 21.43 -2.10 15.05 23.08 20.00 -3.08 15.3 23.87 20.00 -3.87 14.88 23.87 20.00 -3.87 14.65 23.87 20.00 -3.87 14.86 23.87 31.25 7.38
Nurse-Sensitive Serviceline/Unit -Specific Indicators
FIM: Bowel 1.00 1.30 0.30 1.00 1.20 0.20 1.00 1.40 0.40 1.00 1.40 0.40 1.00 1.50 0.50 1.00 1.6 0.60 1.00 1.6 0.60 1.00 1.3 0.30 1.00 1.4 0.40 1.00 1.1 0.10 1.00 1.00 0.00
FIM: Bladder 1.50 1.40 -0.10 1.40 1.50 0.10 1.40 1.40 0.00 1.40 1.60 0.20 1.40 1.50 0.10 1.40 1.4 0.00 1.40 1.4 0.00 1.40 1.1 -0.30 1.40 1.3 -0.10 1.40 1.2 -0.20 1.40 1.50 0.10
Nurse-Sensitive General Indicators
LOS* 4.00 3.79 -0.21 11.80 8.67 -3.13 11.80 8.78 3.02 11.80 9.00 2.80 11.80 8.99 2.81 9.80 8.28 1.52
Mislabeled Sp 0 1 -1 0 3 3 0 1 1 0 2 2 0 1 1 0 1 1 0 0 0 0 0 0 0 2 2 0 1 1 1 0 1
Nurse-Sensitive Patient Satisfaction Survey Indicators
RN Courtesy 87.52 93.80 6.28 87.52 92.70 5.18 87.52 93.10 5.58 87.52 95.10 7.58 87.52 91.80 4.28 83.90 89.30 5.40 93.80 94.00 0.20 88.85 92.70 3.85 88.85 91.40 2.55 88.85 94.6 5.75 88.85 91.2 2.35
Promptness 87.52 86.10 -1.42 87.52 84.00 -3.52 87.52 90.60 3.08 87.52 85.70 -1.82 87.52 83.60 -3.92 84.50 79.50 -5.00 87.00 84.50 -2.50 85.75 84.40 -1.35 85.75 84.10 -1.65 85.75 88.2 2.45 85.75 81.6 -4.15
Attn Spc Needs 87.52 87.00 -0.52 87.52 89.20 1.68 87.52 91.70 4.18 87.52 89.60 2.08 87.52 88.00 0.48 85.30 80.60 -4.70 90.20 87.50 -2.70 87.75 84.70 -3.05 87.75 86.20 -1.55 87.75 90.7 2.95 87.75 84.1 -3.65
Response Pain 87.52 89.50 1.98 87.52 90.30 2.78 87.52 92.50 4.98 87.52 92.40 4.88 87.52 88.60 1.08 86.00 87.00 1.00 90.30 90.30 0.00 88.15 80.00 -8.15 88.15 86.20 -1.95 88.15 89.8 1.65 88.15 85.5 -2.65
Instruct Home 87.52 85.70 -1.82 87.52 84.40 -3.12 87.52 87.20 -0.32 87.52 88.80 1.28 87.52 85.20 -2.32 87.80 81.50 -6.30 89.30 89.60 0.30 88.55 89.70 1.15 88.55 87.80 -0.75 88.55 91.4 2.85 88.55 86.4 -2.15
Care Well Coord 87.52 84.70 -2.82 87.52 87.50 -0.02 87.52 87.90 0.38 87.52 89.20 1.68 87.52 90.20 2.68 88.90 88.00 -0.90 89.80 90.10 0.30 89.35 88.30 -1.05 89.35 86.50 -2.85 89.35 90.6 1.25 89.35 89.2 -0.15
* Estimated Unfavorarble
%PRSSULC = % Patients with pressure ulcers Favorable
%AQPRULC = % Patients with acquired pressure ulcers
%PUPRSRSKA = % Patients who were assessed for pressure ulcers within 24 hours of point-prevalence assessment
TOTFALLS = Total falls/1,000 days
%RSK&PROT = % At risk and on fall protocol
^ With the exception of NHPPD, the target reflects the best quartile performers per NDNQI
^^ NHPPD mean is the NDNQI mean and the target is the Sinai budgeted NHPPD
FIM = Functional Independence Measure
LOS = Length of Stay
NHPPD = Nursing Hours Per Patient Day

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