Quality Measures
Performance Measure Trending Sheet 2011
| Performance Measure | Bench mark | Jan | Feb | Mar | Apr | May | June | July | Aug | Sept | Oct | Nov | Dec |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Total Procedures | |||||||||||||
| Procedure appropiate Biopsies met appropiate criteria | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| Physician Documentation complete | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| Facility maintained in a safe environment | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| Cecal Intubation | > 90%-All colonoscop >95% Screening |
67%-A 41%-S |
75%-A 68%-S |
94%-A 96%-S |
98%-A 97%-S |
98%-A 100%-S |
99%-A 98%-S |
99%-A 100%-S |
95%-A 93%-S |
96%-A 98%-S |
97%-A 94%-S |
97%-A 96%-S |
92%-A 95%-S |
| Patient free from post procedure infection | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| Facility free from Sentinel Event | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
| Patient Satisfaction is good | 95% | 96.0% | 98.2% | 96.3% | 97.8% | 97.2% | 98.5% | 98.1% | 96.9% | 95.0% | 97.0% | 96.3% | 95.6% |
| Adenoma Detection rates Screening Colonoscopy ≥ 25% M and ≥ 15% F | Quarterly | 26%-M 15%-F |
47%-M 28%-F |
38%-M 27%-F |