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Evidence Based Medicine (EBM)
Continue improvement in Evidence Based Medicine metrics as evidence by:
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Each site will attain a composite score of 90% or greater for the following conditions: AMI, HF, PN, SCIP, VTE, and VAP.
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Improve system-wide composite score for Glycemic control to 65%.
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Improve the composite score for Pediatric Asthma to 90%.
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Improve the system-wide composite score for Stroke to 90%.
Patient Safety
Implement strategies to significantly decrease the incidence of Hospital Associated Infections (HAI) as evidenced by:
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Decrease System-wide ICUs VAP rate by 10% from Baseline FY 2007
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Decrease System Hospitals Foley Associated UTI by 15% from Baseline FY 2007
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Decrease System wide and ICU specific Catheter Related BSI by 20% from Baseline FY 2007
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Decrease Hospital-wide MRSA by 10% from Baseline of FY 2007
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Implementation of a Culture of Safety throughout the system
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Complete a Safety Culture Survey
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Improve Medication Reconciliation compliance rate to over 90%.
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