Our dedicated teams of physicians, clinical staff and administrative leaders have begun working on our Clinical Board Goals for 2013. These innovative goals give us the opportunity to continue to spread clinical best practices and improve care across our system.

Each goal has an entry level for improvement, a target goal, and a stretch goal. We urge you, as trustees, to continue to communicate with us on these goals and be our partner in all of our patient safety and quality initiatives. We appreciate your support.


Established by the Intermountain Healthcare Board of Trustees

2013 Clinical Board Goal

Goal – Target

Behavioral Health
Improve planning of post discharge care for inpatient behavioral health patients to meet the 2012 Joint Commission National Quality Measures for Hospital Based Inpatient Psychiatric Services requirements.
Entry: Meet 90% on one measurement
Target: Meet 90% on two measurements
Stretch: Meet 90% on three measurements

Develop a two-year goal establishing a best practice strategy for the treatment of heart failure patients: to accurately identify heart failure patients and apply a consistent care process model that optimizes outcomes across the continuum of care. Each goal will include detailed and specific milestones for years one and two. The Cardiovascular Clinical Program proposes to measure the overall completion of the Clinical Board Goal by producing a composite percentage of completion for each year to be reported at the end of the third quarter of 2013 and 2014 respectively.
This two-year goal is a multi-faceted approach comprised of the four elements listed below:
1. Accurate and timely identification of patients coded with a primary diagnosis of heart failure.
2. Optimize the measurement and reporting systemsfor heart failure patients.
3. Achieve the 2013 Value Based Purchasing and Core Measure heart failure goals.
4. Transition Phase (hospital to home).

Intensive Medicine
Implement electronic physician orders for patients with the primary diagnosis of pneumonia, stroke, and severe sepsis. *All facilities will participate in the goal except Orem Community Hospital, Sanpete Valley Hospital, Sevier Valley Medical Center, Heber Valley Medical Center, Fillmore Community Medical Center, Delta Community Medical Center, Bear River Valley Hospital, Garfield Memorial Hospital, Primary Children's Medical Center, and Cassia Regional Medical Center.

Category Base Entry Target Stretch
Pneumonia  0%  25%  30%  35%
Severe Sepsis  0%  25%  30%  35%
Ischemic Stroke  0%  25%  30%  35%

Intermountain Homecare
Reduce re-hospitalization rates for home health patients by:
  • Monitoring and managing readmissions as they are defined by the Centers for Medicare and Medicaid Services for home health agencies for the Medicare population.
  • Work collaboratively with hospitals to address readmissions through the continuum of care.
  • Identify improvement opportunities in the Home Health discharge to hospital readmission time by analyzing gaps in services.
  • Baseline: 14.12%
    Entry: 13.10%
    Target: 13.00%
    Stretch: 12.60%

    Increase the percentage of newly diagnosed cancer patients with Stage II or higher disease who have documented evidence indicating that they have discussed the seriousness of their illness and possible need for End of Life care.

    20% system baseline rate
    Entry: 25% system rate
    Target: 30% system rate
    Stretch: 35% system rate

    Patient Safety
    Prevent central line associated blood stream infections in all in-hospital patients except bone marrow transplant and acute myelogenous leukemia patients
    Baseline: 1.25/1,000 central line days
    Entry: 1.16/1,000 central line days
    Target: 1.06/1,000 central line days
    Stretch: .91/1,000 central line days

    Pediatric Specialties
    Implement guidelines established in 2011 by the Infectious Disease Society of America for the treatment of community acquired pneumonia in children.
    *The following hospitals are included in this goal: Logan Regional, McKay-Dee Hospital, Primary Children's Medical Center, Riverton Hospital, American Fork, Utah Valley Regional, Valley View Medical and Dixie Regional.
    Baseline: 16%
    Entry: 43%
    Target: 55%
    Stretch: 70%

    Primary Care Clinical Program & SelectHealth
    Establish an individualized approach to diabetic care by engaging patients in self-management, primary care visits and specialty consultations. Improve the percent of Select Health patients age 18 to 75 that meet the diabetes bundle.

    Entry: 29.82%
    Target: 30.07%
    Stretch: 30.51%

    Primary Children's Medical Center
    Reduce ventilator associated pneumonia through improved oral care for pediatric patients who require mechanical ventilation.

    29% compliance
    Entry: 60% compliance
    Target: 70% compliance
    Stretch: 80% compliance rate

    Rural Facilities
    Attain an improved composite rate of compliance to early transfer of Levels I and II trauma patients. Compliance rate of care will reach fifty eight (58) percent by September 30, 2013.
    *Facilities participating in the goal are Bear River, Cassia, Delta, Fillmore, Heber Valley, Park City, Sanpete, and Sevier.
    Baseline:  49%%
    Entry:  53%
    Target:  58%
    Stretch:  63%

    Surgical Services

    Reduce clinically unnecessary blood transfusions and implement bar code blood administration through:
  • Decreasing the number of inpatient orders for two unit packed red blood cell transfusions in the system by 25% compared to a baseline of 2011 data
  • Decreasing the number of inpatient transfusions of packed red blood cells for patients with hematocrits greater than 22% by 25% across the system compared to 2011 data, excluding bone marrow patients
  • Implementing the bar code administration of blood within the operating rooms excluding emergency release blood as well implement the bar code blood administration process at Primary Children's Medical Center including the operating rooms to improve the safety of blood administration in areas with the majority of product administration

  • Entry: Accomplish one of the three projects. 
    Target: Accomplish two of the three projects.
    Stretch: Accomplish three of the three projects.


    Women & Newborns
    Reduce Time for Women in Labor and Delivery through timely administration of the labor inducing medication, oxytocin, within 60 minutes of a woman's admission for a scheduled induction.

    48% of patients have oxytocin started within 60 minutes of admission.
    Entry: 55% of patients will have oxytocin started within 60 minutes of admission.
    Target: 65% of patients will have oxytocin started within 60 minutes of admission.
    Stretch: 70% of patients will have oxytocin started within 60 minutes of admission.

    CMS Value-Based Purchasing
    Attain a significant improvement, approaching the CMS benchmarks, in the CMS VBP clinical process measures for the system by the end of the third quarter 2013 for clinical measures. For outcome measures, achieve a significant improvement based on a percentage increase that either approaches or exceeds national benchmarks.
    Baseline:  44.3%
    Entry:  39.5%
    Target:  35.4%
    Stretch:  29.6%
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