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["Instructions"]
["§        Complete this report quarterly."]
["§        Reports are due on the first working day after the 20th of the month ending the quarter.  For example:  July 2011,  October 2011, and January, 2012  so that the full quarter results will be available."]
["§        Please note that the row for PRC OP results will apply to OP services for the hospitals, and Home Health/Hospice and TCSC results will be entered in that row under their respective column headings."]
["§        Please enter the actual numerators and denominators (x/x) and the percent compliance for each of the metrics where this is applicable."]
[]
["Quarterly Results for Year 2011",null,"MUST HAVES"]
["Regional",null,"1st qtr 2011","2nd qtr 2011","3rd qtr 2011","4th qtr 2011"]
["Service"]
[null,"In-patient overall quality"]
[null,"Outpatient  for hospitals/Home Health/Hospice/TCSC"]
[null,"Outpatient surgery overall quality"]
[null,"Emergency Department overall quality"]
[null,"HCAHPS overall quality"]
[null,"HCAHPS likely to recommend"]
["Quality"]
[null,"ED - Door to physician overall – goal 30” or < (measured in minutes)"]
[null,"ED - Room to provider – goal = 15” or <  (measured in minutes)"]
[null,"ED - Disposition to discharge goal = 30” or < (measured in minutes)"]
["Process Measures / Tactics (% compliance (num/denom)"]
[null,"Leaders rounding on employees - % compliance monthly for the entire hospital"]
[null,"Leader rounding on Out-patients – goals = 25% of patients daily"]
[null,"Leaders rounding on In-patients = % compliance monthly for each department that provides direct care to patients - Goal = 100% daily"]
[null,"Senior Leader rounding on departments = one hour per week"]
[null,"Internal Customer Rounding for Support Services leaders – documentation that support leaders have identified their key customers and number rounded on/quarter versus targeted number"]
["Discharge phone calls - % compliance with monthly targets per department (% Attempts/% Contact)"]
[null,"ED - attempt 100% of those eligible, contact 60% "]
[null,"IP - attempt 100% of those eligible, contact 70% "]
[null,"OP Surgery - attempt 100%, contact 80% "]
[null,"Other OP Depts. - according to target established by the facility for the service. Attempt 100% of those identified; contact 60%."]
["AIDET (% compliance (num/denom)"]
[null,"Use of AIDET by all staff – documentation of at least 10 AIDET audits/month for each department/unit; Calculation: (Total number of Aidet Audits completed for the quarter) / (30 x number of managers)"]
[null,"AIDET orientation for new employees; Calculation: (number of new employees who completed full AIDET orientation) / (number of new employees)"]
["Thank you notes"]
[null,"Write two per week per leader; Calculation: (Total number of Thank you notes wriiten by leaders for the quarter) / (24 x number of leaders)"]