Board of Directors Scorecard Report - Faith Regional Health Services

Scorecard Data is for the period ending March 31, 2008.
Quality
Strategic Growth
Employees
Key Measure
Current
Month
Score
Inpatient Mortality Rate Overall Rating of Hospital Care
Board of Directors Scorecard Report
Key Measure
Reported Medication Error Rate Willingness to Recommend Faith Regional Health Services
Overall Hospital Infection Rate Overall Emergency Department Satisfaction
Surgical Site Infection Rate Overall Outpatient Satisfaction
Unscheduled Readmissions Within 30 Days of Discharge Communication with Nurses
Patient Falls: Acute Care Hospital Communication with Doctors
Patient Falls: St. Joseph’s Rehabilitation & Care Center Responsiveness of Hospital Staff
Acute Myocardial Infarction (AMI) Quality Indicators Pain Management
Chronic Heart Failure (CHF) Quality Indicators Communication about Medicines
Pneumonia Quality Indicators Cleanliness of Hospital Environment
Surgical Care Infection Prevention Quality Indicators Quietness of Hospital Environment
Stroke Quality Indicators 9/2008
Discharge Information
Inpatient Discharges
Operating Margin
Outpatient Registrations Days Cash on Hand
Behavioral Health Acute Unit Patient Days EBIDA Margin
Behavioral Health Progressive Unit Patient Days Net Days in Patient Accounts Receivable
Cardiac Cath. Lab Procedures Compensation as a Percent of Operating Revenue
Operating Room Hours Medical & Drug Supplies as a Percent of Operating Revenue
Sleep Lab Procedures
Other Payers Gross Revenue Percent
Medicare Case Mix Index Current Overall Score 3.53
Total Employee Satisfaction Goal 4.0
My Department Director is respectful and inspires employees
My work is meaningful and personally satisfying
Channels of communication at FRHS keep me informed
I feel appreciated & respected as an individual at FRHS
My work environment promotes balance between work and home
My work culture supports individual values, respect & dignity
2008 Overall Scores:
Customer Satisfaction
Finance
Scoring Guide: Excelling Good Low Risk Mod. Risk High Risk
CMS‐Required Indicators:
Priority Indicators: Noted in bold print.
April 28, 2008
Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sep. Oct. Nov. Dec.
Current
Month
Score

Notes to the March, 2008 Scorecard Report
High Risk Indicators
1. Patient Falls: Acute Care Hospital. This is a baseline value for a new indicator which FRHS will be using as part of its participation in the National
Database of Nursing Quality Indicators (NDNQI).
2. Behavioral Health Progressive Unit Patient Days. Referrals to the inpatient Progressive BHS Unit remain well below expected levels. However, a
lower census in this area also results in lower‐than‐expected contractual adjustments for this service.
3. Cardiac Cath. Lab Procedures.
Moderate Risk Indicators
1. Behavioral Health Acute Unit Patient Days. Referrals to the inpatient Acute BHS Unit remain well below expected levels. However, a lower census
in this area also results in lower‐than‐expected contractual adjustments for this service.
2. Customer Satisfaction Indicators – Willingness to Recommend FRHS. All Customer satisfaction indicator values have been changed for 2008 to
reflect the new CMS‐based reporting system. As a result, all indicators are in the “low risk” to “moderate risk” category. Further explanation of these
changes will be provided at the board meeting.
3. Days Cash on Hand. Currently the reference value for Days Cash on Hand is the value expected on 12/31/2008. However, monthly values for this
indicator are based on a rolling three‐months calculation. Work continues with the Finance Department in an effort to reconcile these to values into a
realistic values for monthly comparison purposes. Until that value is obtained, the Days Cash on Hand Indicator will likely remain in the “high risk”
category.
Sources of Scorecard Data
All data that is used for the FRHS Balanced Scorecard Report is obtained from the following sources:
1. Quality: Organizational, Department and National Database Quality Improvement Reports.
2. Growth: FRHS Organization and Department Strategic Plans and Strategic Benchmark Data.
3. Customer Satisfaction: Quarterly Press Ganey Patient Satisfaction Survey Results.
4. Staff Satisfaction: FRHS Human Resources Department Employee Survey Results.
5. Finance: FRHS Monthly Financial Reports.