MONTH OF JANUARY

INDICATOR GOAL TOTAL

CENSUS
No. of new patients
No. of active patients
No. of transferred
No. of Lost to F/U
Deaths
Hospitalized
Transplanted
TREATMENTS
Total treatments
No. of missed TX
No. of missed TX due to hospitalization
No. of 3x/wk HD patients
No. of 2x/wk HD patients
No. of <2x/wk HD patients
ADEQUACY
Kt/V > 1.4
Kt/V < 1.2
URR > 65
URR < 65
BP AND WEIGHT
Weight gain > 0.5kg
UF > 10ml/kg/hr
BP > 150/90 mmHg
BP < 100/80 mmHg
ANEMIA
Hgb < 10
Hgb > 12
Hgb 10-12
No. of patients transfused
No. of PRBCs transfused
No. of patients on Epo > 8000 u
BONE
Ca. 8.2 – 10 mg/dL
Pi 3.5 – 5.5 md/dL
Pi > 5.5 md/dL
iPTH 100-500
iPTH > 500
NUTRITION
No. of pt. w/ Albumin < 3.8 g/dL
No. of pt. w/ weight loss >5%
ACCESS
No. of AVF
No. of AVG
No. of Temp Catheter < 90 days
No. of Temp Catheter > 90 days
No. of Catheter w/ AVF
No. of Catheter w/ AVG
No. of new pt. with AVF
No. of new pt. with AVG
No. of new pt. w/ Catheter only
INFECTION
No. of pt. w/ fever and/or chills
No. of pt. w/ catheter-related blood infxn
No. of pt. w/ catheter exit site infxn
No. of pt. w/ positive blood culture
No. of organisms cultures
No. of pt. on antibiotic cath-related infxn
HEPATITIC B
No. of pt. w/ Hep B infection
No. of pt. w/ seroconversion
No. of pt. tested for Hep B
No. of pt. w/ hep B surface Abs < 10
No. of pt. w/ ongoing vaccination
HEPATITIC C
No. of pt. w/ hep C infection
No. of pt. w/ new hep C infection
ANNUAL CHEST X-RAYS
Done
Refused
RISK MANAGEMENT
Total treatments
Patient falls
Patient injury not fall
Staff needle stick
Staff back injury
No. of ER transport
No. of medication error
Fire/Earthquake/Emergency Drill
MEDICAL REVIEW
No. Unstable pts. Requiring admission
No. of ACLS Code done
No. Revived & transported by ambulance
No. expired
TECHNICAL
Biomed Equip Inspected/PM
Bldg. and Grounds Inspection
Water culture done
Endotoxin level
Water LAL
Chemical analysis done
Treated Water System
REUSE
Average reuse per failed dialyzer
Patients w/ < 10 reuses
Patients w/ 10 to 20 reuses
Patients on single use
Patients on regular heparin
Patients on low molecular heparin
Patients on flushing schedule
AUDITS
Redcop report
PATIENT SATISFACTION
Grievances
PERSONNEL
Staff Training and Education
Done
Due
Annual PE done/due
Vaccination
Hepatitis B
Flu
 MONTH OF FEBRUARY
INDICATOR GOAL TOTAL
CENSUS
No. of new patients
No. of active patients
No. of transferred
No. of Lost to F/U
Deaths
Hospitalized
Transplanted
TREATMENTS
Total treatments
No. of missed TX
No. of missed TX due to hospitalization
No. of 3x/wk HD patients
No. of 2x/wk HD patients
No. of <2x/wk HD patients
ADEQUACY
Kt/V > 1.4
Kt/V < 1.2
URR > 65
URR < 65
BP AND WEIGHT
Weight gain > 0.5kg
UF > 10ml/kg/hr
BP > 150/90 mmHg
BP < 100/80 mmHg
ANEMIA
Hgb < 10
Hgb > 12
Hgb 10-12
No. of patients transfused
No. of PRBCs transfused
No. of patients on Epo > 8000 u
BONE
Ca. 8.2 – 10 mg/dL
Pi 3.5 – 5.5 md/dL
Pi > 5.5 md/dL
iPTH 100-500
iPTH > 500
NUTRITION
No. of pt. w/ Albumin < 3.8 g/dL
No. of pt. w/ weight loss >5%
ACCESS
No. of AVF
No. of AVG
No. of Temp Catheter < 90 days
No. of Temp Catheter > 90 days
No. of Catheter w/ AVF
No. of Catheter w/ AVG
No. of new pt. with AVF
No. of new pt. with AVG
No. of new pt. w/ Catheter only
INFECTION
No. of pt. w/ fever and/or chills
No. of pt. w/ catheter-related blood infxn
No. of pt. w/ catheter exit site infxn
No. of pt. w/ positive blood culture
No. of organisms cultures
No. of pt. on antibiotic cath-related infxn
HEPATITIC B
No. of pt. w/ Hep B infection
No. of pt. w/ seroconversion
No. of pt. tested for Hep B
No. of pt. w/ hep B surface Abs < 10
No. of pt. w/ ongoing vaccination
HEPATITIC C
No. of pt. w/ hep C infection
No. of pt. w/ new hep C infection
ANNUAL CHEST X-RAYS
Done
Refused
RISK MANAGEMENT
Total treatments
Patient falls
Patient injury not fall
Staff needle stick
Staff back injury
No. of ER transport
No. of medication error
Fire/Earthquake/Emergency Drill
MEDICAL REVIEW
No. Unstable pts. Requiring admission
No. of ACLS Code done
No. Revived & transported by ambulance
No. expired
TECHNICAL
Biomed Equip Inspected/PM
Bldg. and Grounds Inspection
Water culture done
Endotoxin level
Water LAL
Chemical analysis done
Treated Water System
REUSE
Average reuse per failed dialyzer
Patients w/ < 10 reuses
Patients w/ 10 to 20 reuses
Patients on single use
Patients on regular heparin
Patients on low molecular heparin
Patients on flushing schedule
AUDITS
Redcop report
PATIENT SATISFACTION
Grievances
PERSONNEL
Staff Training and Education
Done
Due
Annual PE done/due
Vaccination
Hepatitis B
Flu
 MONTH OF MARCH
INDICATOR GOAL TOTAL
CENSUS
No. of new patients
No. of active patients
No. of transferred
No. of Lost to F/U
Deaths
Hospitalized
Transplanted
TREATMENTS
Total treatments
No. of missed TX
No. of missed TX due to hospitalization
No. of 3x/wk HD patients
No. of 2x/wk HD patients
No. of <2x/wk HD patients
ADEQUACY
Kt/V > 1.4
Kt/V < 1.2
URR > 65
URR < 65
BP AND WEIGHT
Weight gain > 0.5kg
UF > 10ml/kg/hr
BP > 150/90 mmHg
BP < 100/80 mmHg
ANEMIA
Hgb < 10
Hgb > 12
Hgb 10-12
No. of patients transfused
No. of PRBCs transfused
No. of patients on Epo > 8000 u
BONE
Ca. 8.2 – 10 mg/dL
Pi 3.5 – 5.5 md/dL
Pi > 5.5 md/dL
iPTH 100-500
iPTH > 500
NUTRITION
No. of pt. w/ Albumin < 3.8 g/dL
No. of pt. w/ weight loss >5%
ACCESS
No. of AVF
No. of AVG
No. of Temp Catheter < 90 days
No. of Temp Catheter > 90 days
No. of Catheter w/ AVF
No. of Catheter w/ AVG
No. of new pt. with AVF
No. of new pt. with AVG
No. of new pt. w/ Catheter only
INFECTION
No. of pt. w/ fever and/or chills
No. of pt. w/ catheter-related blood infxn
No. of pt. w/ catheter exit site infxn
No. of pt. w/ positive blood culture
No. of organisms cultures
No. of pt. on antibiotic cath-related infxn
HEPATITIC B
No. of pt. w/ Hep B infection
No. of pt. w/ seroconversion
No. of pt. tested for Hep B
No. of pt. w/ hep B surface Abs < 10
No. of pt. w/ ongoing vaccination
HEPATITIC C
No. of pt. w/ hep C infection
No. of pt. w/ new hep C infection
ANNUAL CHEST X-RAYS
Done
Refused
RISK MANAGEMENT
Total treatments
Patient falls
Patient injury not fall
Staff needle stick
Staff back injury
No. of ER transport
No. of medication error
Fire/Earthquake/Emergency Drill
MEDICAL REVIEW
No. Unstable pts. Requiring admission
No. of ACLS Code done
No. Revived & transported by ambulance
No. expired
TECHNICAL
Biomed Equip Inspected/PM
Bldg. and Grounds Inspection
Water culture done
Endotoxin level
Water LAL
Chemical analysis done
Treated Water System
REUSE
Average reuse per failed dialyzer
Patients w/ < 10 reuses
Patients w/ 10 to 20 reuses
Patients on single use
Patients on regular heparin
Patients on low molecular heparin
Patients on flushing schedule
AUDITS
Redcop report
PATIENT SATISFACTION
Grievances
PERSONNEL
Staff Training and Education
Done
Due
Annual PE done/due
Vaccination
Hepatitis B
Flu
 MONTH OF APRIL
INDICATOR GOAL TOTAL
CENSUS
No. of new patients
No. of active patients
No. of transferred
No. of Lost to F/U
Deaths
Hospitalized
Transplanted
TREATMENTS
Total treatments
No. of missed TX
No. of missed TX due to hospitalization
No. of 3x/wk HD patients
No. of 2x/wk HD patients
No. of <2x/wk HD patients
ADEQUACY
Kt/V > 1.4
Kt/V < 1.2
URR > 65
URR < 65
BP AND WEIGHT
Weight gain > 0.5kg
UF > 10ml/kg/hr
BP > 150/90 mmHg
BP < 100/80 mmHg
ANEMIA
Hgb < 10
Hgb > 12
Hgb 10-12
No. of patients transfused
No. of PRBCs transfused
No. of patients on Epo > 8000 u
BONE
Ca. 8.2 – 10 mg/dL
Pi 3.5 – 5.5 md/dL
Pi > 5.5 md/dL
iPTH 100-500
iPTH > 500
NUTRITION
No. of pt. w/ Albumin < 3.8 g/dL
No. of pt. w/ weight loss >5%
ACCESS
No. of AVF
No. of AVG
No. of Temp Catheter < 90 days
No. of Temp Catheter > 90 days
No. of Catheter w/ AVF
No. of Catheter w/ AVG
No. of new pt. with AVF
No. of new pt. with AVG
No. of new pt. w/ Catheter only
INFECTION
No. of pt. w/ fever and/or chills
No. of pt. w/ catheter-related blood infxn
No. of pt. w/ catheter exit site infxn
No. of pt. w/ positive blood culture
No. of organisms cultures
No. of pt. on antibiotic cath-related infxn
HEPATITIC B
No. of pt. w/ Hep B infection
No. of pt. w/ seroconversion
No. of pt. tested for Hep B
No. of pt. w/ hep B surface Abs < 10
No. of pt. w/ ongoing vaccination
HEPATITIC C
No. of pt. w/ hep C infection
No. of pt. w/ new hep C infection
ANNUAL CHEST X-RAYS
Done
Refused
RISK MANAGEMENT
Total treatments
Patient falls
Patient injury not fall
Staff needle stick
Staff back injury
No. of ER transport
No. of medication error
Fire/Earthquake/Emergency Drill
MEDICAL REVIEW
No. Unstable pts. Requiring admission
No. of ACLS Code done
No. Revived & transported by ambulance
No. expired
TECHNICAL
Biomed Equip Inspected/PM
Bldg. and Grounds Inspection
Water culture done
Endotoxin level
Water LAL
Chemical analysis done
Treated Water System
REUSE
Average reuse per failed dialyzer
Patients w/ < 10 reuses
Patients w/ 10 to 20 reuses
Patients on single use
Patients on regular heparin
Patients on low molecular heparin
Patients on flushing schedule
AUDITS
Redcop report
PATIENT SATISFACTION
Grievances
PERSONNEL
Staff Training and Education
Done
Due
Annual PE done/due
Vaccination
Hepatitis B
Flu
 MONTH OF MAY
INDICATOR GOAL TOTAL
CENSUS
No. of new patients
No. of active patients
No. of transferred
No. of Lost to F/U
Deaths
Hospitalized
Transplanted
TREATMENTS
Total treatments
No. of missed TX
No. of missed TX due to hospitalization
No. of 3x/wk HD patients
No. of 2x/wk HD patients
No. of <2x/wk HD patients
ADEQUACY
Kt/V > 1.4
Kt/V < 1.2
URR > 65
URR < 65
BP AND WEIGHT
Weight gain > 0.5kg
UF > 10ml/kg/hr
BP > 150/90 mmHg
BP < 100/80 mmHg
ANEMIA
Hgb < 10
Hgb > 12
Hgb 10-12
No. of patients transfused
No. of PRBCs transfused
No. of patients on Epo > 8000 u
BONE
Ca. 8.2 – 10 mg/dL
Pi 3.5 – 5.5 md/dL
Pi > 5.5 md/dL
iPTH 100-500
iPTH > 500
NUTRITION
No. of pt. w/ Albumin < 3.8 g/dL
No. of pt. w/ weight loss >5%
ACCESS
No. of AVF
No. of AVG
No. of Temp Catheter < 90 days
No. of Temp Catheter > 90 days
No. of Catheter w/ AVF
No. of Catheter w/ AVG
No. of new pt. with AVF
No. of new pt. with AVG
No. of new pt. w/ Catheter only
INFECTION
No. of pt. w/ fever and/or chills
No. of pt. w/ catheter-related blood infxn
No. of pt. w/ catheter exit site infxn
No. of pt. w/ positive blood culture
No. of organisms cultures
No. of pt. on antibiotic cath-related infxn
HEPATITIC B
No. of pt. w/ Hep B infection
No. of pt. w/ seroconversion
No. of pt. tested for Hep B
No. of pt. w/ hep B surface Abs < 10
No. of pt. w/ ongoing vaccination
HEPATITIC C
No. of pt. w/ hep C infection
No. of pt. w/ new hep C infection
ANNUAL CHEST X-RAYS
Done
Refused
RISK MANAGEMENT
Total treatments
Patient falls
Patient injury not fall
Staff needle stick
Staff back injury
No. of ER transport
No. of medication error
Fire/Earthquake/Emergency Drill
MEDICAL REVIEW
No. Unstable pts. Requiring admission
No. of ACLS Code done
No. Revived & transported by ambulance
No. expired
TECHNICAL
Biomed Equip Inspected/PM
Bldg. and Grounds Inspection
Water culture done
Endotoxin level
Water LAL
Chemical analysis done
Treated Water System
REUSE
Average reuse per failed dialyzer
Patients w/ < 10 reuses
Patients w/ 10 to 20 reuses
Patients on single use
Patients on regular heparin
Patients on low molecular heparin
Patients on flushing schedule
AUDITS
Redcop report
PATIENT SATISFACTION
Grievances
PERSONNEL
Staff Training and Education
Done
Due
Annual PE done/due
Vaccination
Hepatitis B
Flu
 MONTH OF JUNE
INDICATOR GOAL TOTAL
CENSUS
No. of new patients
No. of active patients
No. of transferred
No. of Lost to F/U
Deaths
Hospitalized
Transplanted
TREATMENTS
Total treatments
No. of missed TX
No. of missed TX due to hospitalization
No. of 3x/wk HD patients
No. of 2x/wk HD patients
No. of <2x/wk HD patients
ADEQUACY
Kt/V > 1.4
Kt/V < 1.2
URR > 65
URR < 65
BP AND WEIGHT
Weight gain > 0.5kg
UF > 10ml/kg/hr
BP > 150/90 mmHg
BP < 100/80 mmHg
ANEMIA
Hgb < 10
Hgb > 12
Hgb 10-12
No. of patients transfused
No. of PRBCs transfused
No. of patients on Epo > 8000 u
BONE
Ca. 8.2 – 10 mg/dL
Pi 3.5 – 5.5 md/dL
Pi > 5.5 md/dL
iPTH 100-500
iPTH > 500
NUTRITION
No. of pt. w/ Albumin < 3.8 g/dL
No. of pt. w/ weight loss >5%
ACCESS
No. of AVF
No. of AVG
No. of Temp Catheter < 90 days
No. of Temp Catheter > 90 days
No. of Catheter w/ AVF
No. of Catheter w/ AVG
No. of new pt. with AVF
No. of new pt. with AVG
No. of new pt. w/ Catheter only
INFECTION
No. of pt. w/ fever and/or chills
No. of pt. w/ catheter-related blood infxn
No. of pt. w/ catheter exit site infxn
No. of pt. w/ positive blood culture
No. of organisms cultures
No. of pt. on antibiotic cath-related infxn
HEPATITIC B
No. of pt. w/ Hep B infection
No. of pt. w/ seroconversion
No. of pt. tested for Hep B
No. of pt. w/ hep B surface Abs < 10
No. of pt. w/ ongoing vaccination
HEPATITIC C
No. of pt. w/ hep C infection
No. of pt. w/ new hep C infection
ANNUAL CHEST X-RAYS
Done
Refused
RISK MANAGEMENT
Total treatments
Patient falls
Patient injury not fall
Staff needle stick
Staff back injury
No. of ER transport
No. of medication error
Fire/Earthquake/Emergency Drill
MEDICAL REVIEW
No. Unstable pts. Requiring admission
No. of ACLS Code done
No. Revived & transported by ambulance
No. expired
TECHNICAL
Biomed Equip Inspected/PM
Bldg. and Grounds Inspection
Water culture done
Endotoxin level
Water LAL
Chemical analysis done
Treated Water System
REUSE
Average reuse per failed dialyzer
Patients w/ < 10 reuses
Patients w/ 10 to 20 reuses
Patients on single use
Patients on regular heparin
Patients on low molecular heparin
Patients on flushing schedule
AUDITS
Redcop report
PATIENT SATISFACTION
Grievances
PERSONNEL
Staff Training and Education
Done
Due
Annual PE done/due
Vaccination
Hepatitis B
Flu