Quality Measures

Performance Measure Trending Sheet 2014


Performance Measure Bench mark Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
Total Procedures 220 215 223 225
Procedure appropriate Biopsies met appropriate criteria 100% 100% 100% 100% 100%
Physician Documentation complete 100% 100% 100% 100% 100%
Facility maintained in a safe environment 100% 100% 100% 100% 100%
Cecal Intubation > 90%-All colonoscopy > 95% Screening 99%- A
98%-S
91% - A
100% - S
99% - A
99% - S
99% - A
100% - S
97% - A
99% - S
% - A
% - S
% - A
% - S
% - A
% - S
7 - A
% - S
% - A
% - S
% - A
% - S
97% - A
99% - S
Patient free from post procedure infection 100% 100% 100% 100% 100% 100%
Facility free from Sentinel Event 100% 100% 100% 100% 100% 100%
Patient Satisfaction is good 95.00% 97.00% NA 97% 96.00%
Adenoma Detection rates Screening Colonoscopy ≥ 25% M and ≥ 15% F Quarterly 25%-M
13%-F
---- ---- %-M
%-F
---- ---- %-M
%-F
---- ---- %-M
%-F
---- ----