Indicators

Target

Isolation Room
Checks

Air Flow
Negative

Cultures
Whirlpool

Negative

Dialysis

Negative

Endoscopes

Negative

Bronchoscopes

Negative

Nosocomial
Infection Rate
Unknown
Total
UTI
Other Blood Culture
Contamination
Rate
ER
LAB

January

February

March

April

May

June

Jul;y

August September October November December

January

February

March

April

May

June

Ju;y

August

September

October

November

December

January

February

March

April

May

June

Jul;y

August September October November December

MRSA
# of Patients
# of Cultures
MRSA rate
%
SA cultures (%
MRSA/1000 PD)
Hosptial Acquired
Community Acquired
Nsg Home
New cases
WSC
OP
Surveillance
new/known

Indicators
VRE
Hosptial Acquired
Present on
Admission
Nsg Home

MDRP
Hosptial Acquired
Present on
Admission
Nsg Home
Acinetobacter
Baumanii MDR
Present on adm
Hosp acquired
Nsg Home

Target

January

February

March

April

May

June

July

August

September

October

November

December

Handwash
Compliance

January

February

March

April

May

June

July

August

September

October

November

December

Reportable
Diseases

January

February

March

April

May

June

July

August

September

October

November

December

C-Diff
(+ tests)

# Patients
hosp acquired
recurrent
present on
admission
OP
Nursing Home
C-dif rate/100 adm

Hepatitis
HbsAg
HA IGM
HCAb
Shigella
Nisseria Meningitidis
AFB (MTD)
Salmonella
Salmonelli typhi
Tetanus
Dengue fever

Reportable
Diseases

Target

January

February

March

April

May

June

Jul;y

March

April

May

June

August September October November December

Cryptosporidium
Campylobactor
Cryptococcus
Legionella
Giardia
Amoeba
Flu A/B
STD

# / Rx

fox bite
Malaria
Lyme Disease
Neo Herpes
Varicella Zoster

Surgical Site
Infections

Target

December January February

July

August

September October

November

Surgery Center
# of cases
Hospital
# of cases
Employee Health
Indicators

Target

January

February

March

April

May

June

July

August September

October November December

January

February

March

April

May

June

July

August

October

New employees
screened
PPD/CXR
Compliance

100%

Removed from
payroll for non
compliance

Employee
Exposures
Splashes

Needlesticks

High risk=H,
moderate risk=M,
low risk=L
Meningitis exp

September

November

December

Exposure TB

Medical Office
Biological
Indicators of
autoclaves
Indicator results

Negative
Tests

Compliance with
procedure

100%

MRSA
SURVEILLANCE
CCU
# OF ADMISSIONS
Negative
Positive
Not done
Total
Treated
Not treated
Nursing home
Known MRSA
SA pos
Other organisms

January

February

March

April

May

June

July

August September October November December

January

February

March

April

May

June

July

August September October November December

Indicators

Target

Isolation Room
Checks

Air Flow
Negative

January

February

March

April

May

June

Jul;y

August

January

February

March

April

May

June

Ju;y

August

January

February

March

April

May

June

Jul;y

August

Cultures
Whirlpool

Negative

Dialysis

Negative

Endoscopes

Negative

Bronchoscopes

Negative

Nosocomial
Infection Rate

6.00%

Unknown
Total
UTI
Other Blood Culture
Contamination
Rate

3.0%

ER
LAB
MRSA
# of Patients
# of Cultures
MRSA rate
%
SA cultures (%
MRSA/1000 PD)
Hosptial Acquired
Community Acquired
Nsg Home
New cases
WSC
OP

Indicators
VRE
Hosptial Acquired
Present on
Admission
Nsg Home

MDRP

Target

Hosptial Acquired
Present on
Admission
Nsg Home
Acinetobacter
Baumanii MDR
Present on adm
Hosp acquired
Nsg Home
January

February

March

April

May

June

July

August

January

February

March

April

May

June

July

August

January

February

March

April

May

June

July

August

January

February

March

April

May

June

Jul;y

August

C-Diff
(+ tests)

# Patients
hosp acquired
recurrent
present on
admission
OP
Nursing Home
C-dif rate/100 adm

1.0%

Handwash
Compliance
95%
Reportable
Diseases

Hepatitis
HbsAg
HA IGM
HCAb
Shigella
Nisseria Meningitidis
AFB (MTD)
Salmonella
Salmonelli typhi
Tetanus
Dengue fever

Reportable
Diseases

Target

Cryptosporidium
Campylobactor
Cryptococcus
Legionella
Giardia
Amoeba
Flu A/B
STD
fox bite
Malaria
Lyme Disease
Neo Herpes

# / Rx

Varicella Zoster

Surgical Site
Infections

Target

Surgery Center

2.6%

December January February

March

April

May

June

July

# of cases
Hospital

2.6%

# of cases
Employee Health
Indicators

Target

January

February

March

April

May

June

July

August

January

February

March

April

May

June

July

August

January

February

March

April

May

June

July

August

New employees
screened
PPD/CXR
Compliance

100%

Removed from
payroll for non
compliance

Employee
Exposures
Splashes

Needlesticks

High risk=H,
moderate risk=M,
low risk=L
Meningitis exp
Exposure TB

Medical Office
Biological
Indicators of
autoclaves
Indicator results

Negative
Tests

Compliance with
procedure

100%

September

October

September

October

September

October

November December

November

December

November December

September

October

November

December

September

October

November

December

September

October

November

December

September

October

November December

August

September

September

October

September

October

September

October

October

November

November December

November

December

November December