Page 52 - COPR-Oct 2017

Appendix — Amazing Patient Care

KPI Name System Leader Measure Definition
Inpatient & ED Phyllis Inpatient
Patient Experience Doulaveris Numerator: Number of top-box responses Denominator: Total responses.
Based on the Press Ganey survey question rating hospitals from 0 to 10. Ratings of
9 or 10 are considered “top-box.” The system and region scores are averages of the
individual hospital scores, weighted by hospital volume.
Emergency Department (ED)
Numerator: Number of top-box responses Denominator: Total responses
Based on the Press Ganey survey question rating ED care. The top-box score is a
rating of 5. The system and region scores are averages of the individual ED scores,
weighted by ED volume.
7 Day Follow-Up Cathy Follmer Numerator: Post-discharge population health patients scheduled within 7 days for
(high readmission an MHP provider visit.
risk PHP) Denominator: Total number of population health patients Patient population meets
the following criteria:
• observation or inpatient status
• Geisinger score >=14
• discharged to home
Hospital Acquired Dr. Jim Kravec Observed instances of urinary-tract infections, bloodstream infections, Clostridium
Infections difficile infections, MRSA bacteria, and surgical site infections after colon surgeries
and hysterectomies, according to the National Healthcare Safety Network’s
definition/expected values and risk methodology. All acute inpatients meeting the
NHSN criteria for inclusion in the population.
ED Visits per Dr. Bernadette Numerator: Total Emergency Department (ED) visits incurred during period
1,000 Deguzman Denominator: Average covered members for the same time period. ED Visits/1000
is the annualized number of employee health and MSSP members with an ED visit
per 1000 covered lives. ED visits that led to an admission are not included. Data
source changed from claims to more current domestic Epic data combined with a
historic non-domestic factor. See Hub page for more details.

Admissions per Dr. Amy Numerator: Total admissions incurred during period
1,000 Frankowski Denominator: Average covered members for the same time period
Admissions/1000 is the annualized number of employee health and MSSP
members admitted for an inpatient hospital stay per 1000 covered lives. All types
of inpatient admissions are counted (including ED visits that led to admission).
Data source changed from claims to more current domestic Epic data combined
with a historic non-domestic factor. See Hub page for more details.
Door to Provider Cheryl Admit Order to Floor: Total number of minutes from emergency department
& Admit Order to Dalton-Norman physician’s decision to admit to the patient being admitted to the floor.
ED Departure Door to Provider: Minutes from patient arrival “quick registration” in CarePATH to
physician interaction with patient documented in CarePATH.
Likelihood to Dr. Erin Fries Numerator: Number of top-box responses
Recommend Denominator: Total responses.
Provider Office Based on the Press Ganey survey question, “Would you recommend this provider’s
office to your family and friends?” The top-box response is “Yes, definitely.” Results
are reported based on month of service.
MyChart Response Anita Mattingly Numerator: # of messages that received a response within timeliness criteria
Timeliness Denominator: Total messages
Messages received before 4pm on business days should receive a response by
midnight. Messages received after 4pm on business days or on a weekend /
holiday should receive a response by noon the next business day.
The types of messages to be measured include:
• Patient medical advice request • Patient HM schedule request
• Patient medication renewal request • User message
• Patient appointment schedule request • Patient customer service request
• Patient appointment cancel request • Patient demographics update request

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