Measurement Table
Measure Name & Description
(Outcome / Process /
Balancing)
Project: Improving Pediatric Critical Care (IPCC)
How Calculated
X Axis
Owners: T. Willis, A. Purdy
Y Axis
Graph Title
Date: August 24, 2011
Goal
Line
Data
Collection
Instrument
Data
Collection
Plan
Infinity
Hospital
epidemiology
chart review
Hospital Epi
confirms case
Data
Reporting
Plan
REDUCING HOSPITAL-ACQUIRED INFECTIONS
Days Between VAPs
Outcome Measure
1) Calendar days between
ventilator-associated pneumonia
(VAP) events in the Pediatric
Intensive Care Unit (PICU)
Target Population: All ventilated patients in
the PICU
Special Instructions (e.g., rolling average,
handling missing data, etc.): G chart for rare
events. For instances where multiple
infections occur on the same date, do not use
zero for days between. Ex.) 2/day, use 0.5 for
the second event;
Label:
Event
Label: Days
Between
Scale:
1 - current
number of
VAPs
Scale:
0 - 225
Calendar Days
Between VAPs in
the PICU
Hospital Epi:
report via ‘days
since’ emails
Analyst: add
dates to
spreadsheet
(April 2008 –
present)
Note: VAP rate (infections per 1000
ventilator-days) is also tracked & updated
quarterly. YTD rate is displayed in table
format. FY11 goal is zero VAPs.
Days Between CLABSIs
Outcome Measure
2) Calendar days between central
line-associated blood stream
infection (CLABSI) events in the
PICU
HAI team is also alerted to suspected cases
via emails from Hospital Epi.
Target Population: All patients with a central
line in the PICU
Special Instructions: G chart for rare events.
For instances where multiple infections occur
on the same date, do not use zero for days
between. Ex.) 2/day, use 0.5 for the second
event;
Label:
Event
Label: Days
Between
Scale: 1current
number of
CLABSIs
Scale:
0 - 250
Days Between
CLABSIs in the
PICU
Infinity
Hospital
epidemiology
chart review
Hospital Epi:
report via ‘days
since’ emails
Analyst: add
dates to
spreadsheet
Days Between CAUTIs
Outcome Measure
3) Calendar days between Foley
catheter-associated urinary tract
Special Instructions: G chart for rare events.
For instances where multiple infections occur
PICU RN:
post ‘days
since’ flyers
in PICU
Analyst:
Update
PIQME
monthly;
website
quarterly
PICU RN:
post ‘days
since’ flyers
in PICU
(January 2006
– present)
Note: CLABSI rate (infections per 1000 central
line-days) is also tracked & updated quarterly.
YTD rate is displayed in table format. FY11
goal is zero CLABSIs.
HAI team is also alerted to suspected cases
via emails from Hospital Epi.
Target Population: All patients with a Foley
catheter in the PICU
Analyst:
Update
PIQME
monthly;
website
quarterly
Label:
Event
Label: Days
Between
Scale: 1current
Scale:
0 - 140
Days Between
CAUTIs in the
PICU
Infinity
Hospital
epidemiology
chart review
Hospital Epi:
report via ‘days
since’ emails.
Analyst: add
Analyst:
Update
PIQME
monthly;
website
Measure Name & Description
(Outcome / Process /
Balancing)
infections (CAUTI) events in the
PICU
How Calculated
X Axis
on the same date, do not use zero for days
between. Ex.) 2/day, use 0.5 for the second
event;
Note: CAUTI rate (infections per 1000 Foley
catheter-days) is also tracked & updated
quarterly. YTD rate is displayed in table
format. FY11 goal is zero CAUTIs.
Hand Hygiene Compliance
Process Measure
4) Hand hygiene compliance
amongst all faculty, staff, and
family members in the PICU
HAI team is also alerted to suspected cases
via emails from Hospital Epi.
Target Population: All faculty, staff, and
family members who come into contact with
patients or the patient's environment
Numerator: Total number of observations of
proper hand hygiene
Denominator: Total number of observations
of proper and improper hand hygiene
(minimum = 10)
Special Instructions: P Chart; Observations
with <10 opportunities are excluded from the
analysis.
Y Axis
Graph Title
Goal
Line
Data
Collection
Instrument
number of
CAUTIs
Data
Collection
Plan
dates to
spreadsheet
quarterly
PICU RN:
post ‘days
since’ flyers
in PICU
(January 2006
– present)
Label:
Observation
number (or
date of
observation)
Data
Reporting
Plan
Label:
Compliance
percentage
PICU Hand
Hygiene
Compliance
100%
Hand hygiene
observation
tool or iScrub
Lite.
Scale: 0 - 100
Scale: 1-total
number of
observations
Volume: 3
observations
Frequency:
Weekly
Analyst:
Update
PIQME
monthly;
website
quarterly
Analyst: Collect
completed
observation
forms from
envelope at unit
dashboard; Add
results from
paper forms and
iScrub emails to
spreadsheet
(Nov 2008 present)
Note: Immediate feedback/ education should
be provided to those who were observed –
both positive & negative.
PEDIATRIC RAPID RESPONSE SYSTEM
Family Awareness of PRRS
Process Measure
5) Percentage of families, based
on surveys, who are familiar with
the PRRS and can explain how
family members can properly
activate the system
Target Population: Family members of
inpatients at NCCH (5, 6, 7 Children's & CICC)
Numerator: Number of families who
demonstrated accurate knowledge and
understanding
Denominator: Total number of families
surveyed
Special Instructions: P Chart; Exclude empty
Label:
Survey
number (or
date of
survey)
Scale: 1 - total
number of
surveys
conducted
Label:
Awareness
percentage
Scale: 0 - 100
PRRS Family
Awareness
85%
Family
Awareness
Audit Tool
Volume: 1
survey per unit
Frequency:
Monthly
RN champions:
conduct audits
& send results
to Analyst via
campus mail
Analyst:
Update
PRRS
Committee
monthly;
website &
PIQME
quarterly
Measure Name & Description
(Outcome / Process /
Balancing)
Pediatric Rapid Response Calls
1000 Discharges
Process Measure
6) Number of PRRS calls per 1000
discharges at NCCH
How Calculated
X Axis
rooms and rooms with unavailable family
members from the count.
(Oct 2007 present)
Target Population: PRRT calls made on behalf
of all non-ICU/ED patients at NCCH by any
faculty, staff, or family member
Label:
Month
Scale: Aug
2005 present
Numerator: Total number of calls*1000
Y Axis
Label: Calls
per 1000
discharges
Graph Title
Goal
Line
PRRT Calls Per
1000 Discharges
Data
Collection
Instrument
Telecommunications call log
(for raw data)
Scale: 0 - 70
PRRS Call
Forms
(completed by
team after call)
Denominator: Discharges
Special Instructions: I Chart
NCCH monthly
discharges
(5,6,7
Children’s &
CICC)
Note: PRRT calls per month chart is available
for use when discharge data are not current.
Days Between non-ICU/ED
Cardiac Arrests
Outcome Measure
7) Calendar days between nonICU/ED cardiac arrests at NCCH
Target Population: All non-ICU/ED patients at
NCCH
Special Instructions: G chart for rare events.
For instances where multiple events occur on
the same date, do not use zero for days
between. Ex.) 2/day, use 0.5 for the second
event.
Label:
Cardiac Arrest
Event
Label: Days
Between
Scale: 0 - 450
Calendar Days
Between NonICU/ED Pediatric
Cardiac Arrests
Infinity
Scale: 1current
number of
CAs
Telecommunications call log
(for raw data)
MD Review of
Code Calls
Data
Collection
Plan
Analyst: add
results to
spreadsheet
Frequency:
Monthly
Analyst:
abstract
pediatric events
from Telecommunications
emergency call
log & enter call
details into
spreadsheet.
Additional fields
completed with
data from PRRT
Call Forms.
PICU Med
Director: Notify
Ashley when a
CA has
occurred.
Analyst: add
dates to
spreadsheet
Note: MD must assess each code call to
determine if CA occurred. FY11 goal is zero
non-ICU/ED pediatric CAs.
Data
Reporting
Plan
Analyst:
Update
PRRS
Committee
monthly;
website &
PIQME
quarterly
Analyst:
Report via
‘days since’
emails
weekly;
Update
PRRS
monthly;
PIQME &
website
quarterly
PICU RN:
post ‘days
since’ flyers
in PICU
IMPROVING COMMUNICATION SYSTEMS
Daily Goals Communication Sheet
Compliance
Process Measure
Target Population: All care team providers of
patients in the PICU
Label:
Audit
Label:
Compliance
Percentage
PICU Daily Goals
Communication
Sheet
100%
IPCC DG data
collection tool
Volume: 1 audit
Frequency:
Analyst:
Update
PIQME &
Measure Name & Description
(Outcome / Process /
Balancing)
8) Percentage of completed
quality control measures and
team member signatures on Daily
Goals Communication Sheets for
all patients in the PICU
How Calculated
Numerator: Number of completed quality
control measures and team member
signatures.
X Axis
Scale: 1current
number of
audits
Y Axis
Graph Title
Goal
Line
Data
Collection
Instrument
Compliance
Data
Collection
Plan
Monthly
Scale: 0 - 100
Data
Reporting
Plan
website
quarterly
Analyst:
perform audit
and add results
to spreadsheet
Denominator: Total number of quality control
measures and signature opportunities for all
patients rounded on in the PICU. (Obtain
printout of PICU census from HUC. Confirm
with Attending or Fellow if any patients were
not presented during rounds.)
Special Instructions: P’ Chart (Originally
analyzed on a P Chart, but appeared
overdispersed due to large data set.)
Target Population: All patients in the PICU
Morning Bedside Rounds
Efficiency
Balancing Measure
9) Length of morning bedside
rounds (minutes per patient)
Numerator: Total time of morning bedside
rounds (in minutes)
Denominator: Total number of patients
rounded on in the PICU
Label: Date
Scale: 1current
number of
dates tracked
Label:
Minutes per
patient
Length of
Morning Bedside
Rounds in the
PICU
8
IPCC SR data
collection tool
PICU Fellows/
Attendings:
record start/
end times and
number of
patients
rounded on
Scale: 2 - 20
Special Instructions: I Chart
Frequency: prn
Analyst: Collect
data and add to
spreadsheet
Analyst:
Update
PIQME &
website
quarterly
Note: Rounds time data collection tools
available in the unit for prn use.
PARTNERING WITH FAMILIES
Family Satisfaction
Outcome Measure
10) Percentage of families, based
on surveys and interviews, who
would recommend NCCH PICU to
others
Target Population: All PICU families
Numerator: Number of families who answer
yes when asked if they would recommend
NCCH PICU to others.
Denominator: Total number of families
surveyed
Special Instructions: Run chart
Label: Survey
Scale: 1current
number of
families
surveyed
Label:
Satisfaction
Percentage
Scale: 0 - 100
PICU Family
Satisfaction
100%
Data collected
via PICU
Questionnaire
(#7) or during
FCC Specialist
rounds
(interviews).
Volume: 10
Frequency:
Monthly
FCC Specialist:
Send previous
month’s data to
Analyst during
the first week of
each month
Analyst:
Update
PIQME
monthly;
website
quarterly
Measure Name & Description
(Outcome / Process /
Balancing)
How Calculated
X Axis
Y Axis
Graph Title
Goal
Line
Data
Collection
Instrument
Data
Collection
Plan
Data
Reporting
Plan
Analyst: Add
data to
spreadsheet
Family Complaints
Outcome Measure
11) Number of patient complaints
to the Patient Relations
department from families of
patients in the PICU
Target Population: All PICU families
Numerator: PICU patient/family complaints
made to the Patient Relations department.
Label: Month
Scale: Jan
2008-present
Label:
Number of
complaints
PICU Family
Complaints
0
Patient
Relations
database
Frequency:
Monthly
FCC Specialist:
Send previous
month’s data to
Ashley during
the first week of
each month
Scale: 0 - 5
Special Instructions: Run chart; Excluded
financial complaints.
Analyst:
Update
PIQME
monthly;
website
quarterly
Analyst: Add
data to
spreadsheet
Daily Communication with
Families
Process Measure
12) Percentage of PICU families
(primary caregivers) who receive
a daily update regarding their
child’s condition and plan of care
Target Population: All PICU families
Label: Month
Numerator: Number of PICU families that
receive a daily update from a provider and a
nurse
Scale:
October 2010
- present
Label:
Proportion
Scale: 0 – 1.0
Daily
Patient/Family
Update from
Provider and
Nurse
Green Belt
team data
collection tool
Volume: 1 audit
Frequency:
Daily
Green Belt
Team: collect
and report data
to Black Belt
Leader
Denominator: Total number of PICU families
Special Instructions: P Chart
Black Belt
and Green
Belt team:
Update
Blue Belts
and PIQME,
as available
Black Belt
Leader to add
data to
spreadsheet
PICU Staff Perception of
Patient- and Family-Centered
Care
Balancing Measure
13) PICU staff perceptions of
patient and family-centered care
Target Population: PICU staff
Label:
Survey
Special Instructions: Pre-/Post bar graphs.
Scale: PrePost-implementation
Label:
Percentage of
staff
perceiving
FCC as
excellent or
above
PICU Staff
Perception of
Patient- and
Family-Centered
Care
(Improve
from
baseline)
IPCC Survey
Frequency:
Two. Pre-/postimplementation
surveys
Analyst:
Distribute
Analyst:
Report to
PIQME at
end of
project.
Measure Name & Description
(Outcome / Process /
Balancing)
How Calculated
X Axis
Y Axis
Graph Title
Goal
Line
Data
Collection
Instrument
average
Data
Collection
Plan
Data
Reporting
Plan
survey & collect
responses via
Survey Monkey;
Scale: 0 -100
Add data to
spreadsheet.
PICU Staff Valuation of Patientand Family-Centered Care
Balancing Measure
14) PICU staff valuation of
patient- and family-centered
care.
Target Population: PICU staff
Label:
Survey
Special Instructions: Pre-/Post bar graphs.
Scale: Pre/Post-implementation
Label:
Percentage of
staff valuing
FCC as very
important or
important
Scale: 0 -100
PICU Staff
Valuation of
Patient- and
Family-Centered
Care
(Improve
from
baseline)
IPCC Survey
Frequency:
Two. Pre-/postimplementation
surveys
Analyst:
Distribute
survey & collect
responses via
Survey Monkey;
Add data to
spreadsheet.
Analyst:
Report to
PIQME at
end of
project.