HAAD JAWDA Quality KPI; waiting times. December 2015

Transcription

1 HAAD JAWDA Quality KPI; waiting times December 2015 Page 1 of 13

2 Type: Waiting Time Indicator Indicator Number: WT001 Primary Care Appointment- Outpatient Setting Time to see a HAAD licensed family physician or member of their team (GP) Time of request (walk-in or by phone) to seeing the doctor Number of patients that were seen within 48 hours of requests DIVIDED by the number of all requests that attended Exclusions : 1) Non Physician Led Appointment Types 2) Follow Up Appointment Types 3) Dentist 4) Emergency Patients 5) Patient choice of not having the appointment within 48 hours when offered % for performance (hours for mean, median and min. & max) 90% within 48 hours -Local business intelligence report or any other internally designed system - Applicable to licensed operational general and specialist hospitals for provision of primary care and/or specialist/consultant outpatient facilities Page 2 of 13

3 Type: Waiting Time Indicator Indicator Number: WT002 Referral of Suspected Cancer Cases Time for a HAAD licensed relevant specialist/ consultant to see a patient with suspected cancer from time of receiving the referral Time from receiving the referral (or self-request for appointment) to seeing a relevant specialist/consultant Number of patients with suspected cancer that got seen by the relevant HAAD licensed specialist/consultant within 2 weeks (or 14 calendar days) from receiving the referral (or self-requested appointment) DIVIDED by the number of all attended referred (selfreferred) patients with suspected cancer Populations: All suspected cancer cases Exclusions : 1) Non Physician Led Appointment Types 2) Follow Up Appointment Types % for performance (days for mean, median and min. & max) 90% within 14 calendar days - Applicable to licensed operational general and specialist hospitals for provision of primary care and/or specialist/consultant outpatient facilities - Referral forms or data base Page 3 of 13

4 Type: Waiting Time Indicator Indicator Number: WT003 Hospital Wait at Point of Arrival Time in minutes from registration to seeing a specialist or consultant Minutes difference from registration in attendance to seeing the specialist or consultant Number of patients that were seen within 60 minutes DIVIDED by the number of all patients registering Exclusions : - Non Physician Led Appointment Types - Patients that required investigation done prior to seeing the doctor, as part of efficient process e.g.; hearing test, treadmill test, ECG, blood glucose, etc.. 90% within 60 minutes - Applicable to licensed operational general and specialist hospitals for provision of primary care and/or specialist/consultant outpatient facilities Page 4 of 13

5 Type: Waiting Time Indicator Indicator Number: WT004 Consultant or specialist Hospital Appointment (excluding cancer) Time for a HAAD-licensed specialist or consultant to see a nonsuspected cancer case Time from receiving the referral (or self-request for appointment) to seeing a relevant specialist/consultant Number of patients that got seen by the relevant HAAD licensed specialist/consultant within 2 weeks (or 14 calendar days) from receiving the referral (or self-requested appointment) DIVIDED by the number of all referred (by all referred and/or self-requests) that attended Exclusions: 1) For / To Oncology Clinics 2) Non Physician Led Appointment Types 3) Follow Up Appointment Types % for performance (days for mean, median and min. & max) 90% within 14 calendar days - Applicable to licensed operational general and specialist hospitals for provision of primary care and/or specialist/consultant outpatient facilities Page 5 of 13

6 Type: Waiting Time Indicator Indicator Number: WT005 Hospital Inpatient or day case (inpatient) Number of days it takes to admit a non- emergency patient from DTA (decision to admit) made by a HAAD licensed specialist or consultant Number of days from date of DTA (Decision to Admit) to nonemergency patient being admitted (DTA is day zero) for procedure and non-procedure based activities Number of patients being admitted within 28 days of DTA DIVIDED by all patients with DTA within the same set period Population: All elective admissions with DTA Exclusion: 1. Patients who are unable to have their treatment for social, work or personal reasons 2. Patients who choose to wait longer than 4-weeks for their treatment 3. Patients for whom it is not clinically appropriate to start treatment within 4 weeks 4. Delay in admission due to insurance approval being refused or delayed >= 14 days 5. Emergency admissions % for performance (days for mean, median and min. & max) 90% within 28 calendar days - Applicable to facilities licensed to provide inpatient services Page 6 of 13

7 Type: Waiting Time Indicator Indicator Number: WT006 Door to Balloon (PCI) time for patients with ACAS Number of minutes it takes to start angiogram/plasty for emergency patients with ACAS diagnosis Acute myocardial infarction (AMI) patients with ST-segment elevation or LBBB on the ECG closest to arrival time receiving primary PCI during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less Number of patients having angiogram or angioplasty within 90 minutes DIVIDED by the number of all patients attending or registering with ACAS, AMI patients with ST-elevation or LBBB on ECG who received primary PCI Numerator: Number of patient who had primary angiogram/plasty within 90 min of attending as an emergency With ACAS Numerator Inclusions: n/a Numerator Exclusions: None Denominator: Number of all patients attending or registering with ACAS AMI patients with ST-elevation or LBBB on ECG who are indicated to receive primary PCI Denominator Inclusions: Discharged patients with: o An ICD-9-CM Principal Diagnosis Code for AMI: AMI ANTEROLATERAL,UNSPEC AMI ANTEROLATERAL, INIT AMI ANTERIOR WALL,UNSPEC AMI ANTERIOR WALL, INIT AMI INFEROLATERAL,UNSPEC AMI INFEROLATERAL, INIT AMI INFEROPOST, UNSPEC AMI INFEROPOST, INITIAL Page 7 of 13

8 AMI INFERIOR WALL,UNSPEC AMI INFERIOR WALL, INIT AMI LATERAL NEC, UNSPEC AMI LATERAL NEC, INITIAL TRUE POST INFARCT,UNSPEC TRUE POST INFARCT, INIT SUBENDO INFARCT, UNSPEC SUBENDO INFARCT, INITIAL AMI NEC, UNSPECIFIED AMI NEC, INITIAL AMI NOS, UNSPECIFIED AMI NOS, INITIAL AND o ICD-9-CM Principal and Other Procedure Codes for Percutaneous Coronary Intervention (PCI): PTCA AND/ OR o ST-segment elevation or LBBB on the ECG performed closest to hospital arrival AND o PCI performed within 24 hours after hospital arrival Denominator Exclusions: Patients less than 16 years of age In-Patients Patients enrolled in clinical trials Patients administered fibrinolytic agent or any counter indication agent prior to PCI in another facility if indicated PCI described as non-primary by a physician/advanced practice nurse/physician assistant (physician/apn/pa) PCI is clinically contraindicated 90% within 90 minutes - Applicable to facilities licensed to provide inpatient services Page 8 of 13

9 Type: Waiting Time Indicator Indicator Number: WT007 Stroke Admission with CT scan timeframe Number of minutes it takes to start head CT-emergency scan for patients presenting with suspected stroke Number of minutes from registration or attending to start of emergency CT-scan of head Number of patients having an emergency head CT-Scan for acute Stroke within 3 hours DIVIDED by all patients attending or registering with suspected stroke Numerator: Patients with suspected acute stroke who had a CT- Scan of the head within 180 minutes of arrival to ED. Denominator: All adult Patients (>=16 years old) who are suspected of having an acute stroke who have visited ED departments. Patients who arrive to ED with ACUTE symptoms suggestive of stroke, or defined as ischemic and hemorrhagic stroke patients. Suspected Acute Discharge, ICD9: , , , , , , , , , 436, 430, 431 Exclusion: a. Patients below 16 years of age. b. Clinically unstable patients. 90% within 180 minutes - Applicable to facilities licensed to provide inpatient services Page 9 of 13

10 Type: Waiting Time Indicator Indicator Number: WT008 Seeing a doctor in Accident and Emergency Number of minutes it takes from point of registration to seeing a doctor Number of patients seen within 60 minutes DIVIDED by all patients registering in A&E Population: All emergency encounters Exclusion: 1) Deceased on Arrival (DOA) 2) Patient Left Without Being Seen (LWBS) 90% within 60 minutes - Applicable to facilities licensed to provide emergency and inpatient services Page 10 of 13

11 Type: Waiting Time Indicator Indicator Number: WT009 Registration to leaving Accident and Emergency Department Number of minutes from registration to patient leaving the department (admitted, discharged, deceased) Number of patients that left the A & E department within 120 minutes DIVIDED by all patients attending A & E Population: All emergency encounters ( irrespective of triage category) Exclusion: 1) Deceased on Arrival (DOA) 90% within 120 minutes - Applicable facilities licensed to provide emergency and inpatient services Page 11 of 13

12 Type: Waiting Time Indicator Indicator Number: WT010 Emergency Ambulance response time in Urban Areas Time, in minutes, it requires an ambulance to arrive to emergency scene in an urban areas from time of request Number of ambulance responses that arrived at scene within 15 minutes of request DIVIDED by all requests from urban areas Population: All actioned ambulance calls Exclusion: 1) non-dispatched calls 2) inter-facilities transfer e.g., clinic to hospital or hospital to hospital 90% within 15 minutes - Ambulance provider intelligence report or any other internally - Applicable to licensed ambulance services Page 12 of 13

13 Type: Waiting Time Indicator Indicator Number: WT011 Emergency Ambulance response time in Rural Areas Time, in minutes, it requires an ambulance to arrive to emergency scene in a rural areas from time of request Number of ambulance responses that arrived at scene within 19 minutes of request DIVIDED by all requests from urban areas Population: All actioned ambulance calls Exclusion: 3) non-dispatched calls 4) inter-facilities transfer e.g., clinic to hospital or hospital to hospital 90% within 19 minutes - Ambulance provider intelligence report or any other internally - Applicable to licensed ambulance services Page 13 of 13