Ejada Performance Intervention Report
Hospital Name: Al Noor Hospital
Date: 22 March 2025
Reporting Authority: National Ejada Oversight Committee
Executive Summary:
Al Noor Hospital has demonstrated critical underperformance across multiple Ejada pillars, with a total performance score of 38%. Persistent gaps in clinical outcomes, operational efficiency, patient experience, and innovation require urgent action. This report outlines the key areas of concern and recommends intensive corrective measures including structural, staffing, and digital interventions.
1. Clinical Excellence
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| 30-day Readmission Rate | <10% | 22.4% | +12.4% | Critical |
| Surgical Site Infection Rate | <1.5% | 3.5% | +2.0% | Critical |
| Antimicrobial Stewardship Compliance | >90% | 51% | -39% | Critical |
| Mortality Index (HSMR) | <1.0 | 1.7 | +0.7 | Critical |
Issues Identified:
- Non-compliance with clinical protocols
- Inconsistent mortality reviews
- Poor infection control infrastructure
Recommended Corrective Actions:
- Deploy real-time clinical decision support tools
- Establish mortality & morbidity review committee
- Implement mandatory antimicrobial prescribing policy
2. Operational Efficiency
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| ED Waiting Time (mins) | <45 | 132 | +87 | Critical |
| Average LOS (days) | 4.0 | 7.5 | +3.5 | Critical |
| OR Utilization Rate | >80% | 43% | -37% | Critical |
| Discharge Before Noon | >60% | 29% | -31% | Critical |
Issues Identified:
- Systemic bottlenecks in ED to ward transfers
- Lack of discharge planning protocols
- Poor OR scheduling discipline
Recommended Corrective Actions:
- Implement real-time ED command center dashboard
- Assign full-time discharge coordinators
- Review and rebalance OR block allocations
3. Financial Sustainability
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| Claims Rejection Rate | <5% | 17% | +12% | Critical |
| Average Revenue per Encounter | AED 600 | AED 380 | -220 | Underperforming |
| Documentation Compliance Rate | >95% | 62% | -33% | Critical |
Issues Identified:
- Frequent coding errors due to incomplete documentation
- Low physician engagement in revenue cycle compliance
Recommended Corrective Actions:
- Deploy AI-based CDI solution
- Conduct monthly training on documentation and billing
- Establish financial KPI accountability per department
4. Patient Experience
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| Overall Patient Satisfaction | >85% | 53% | -32% | Critical |
| Staff Courtesy (PREM Domain) | >90% | 64% | -26% | Critical |
| Noise Level at Night (HCAHPS) | <10% complaints | 33% | +23% | Critical |
| Pain Management Effectiveness (PROM) | >85% | 49% | -36% | Critical |
| Understanding of Post-Discharge Instructions (PREM) | >90% | 55% | -35% | Critical |
Issues Identified:
- High dissatisfaction due to poor communication and empathy
- Suboptimal pain management
- No active feedback response mechanism
Recommended Corrective Actions:
- Launch Patient Experience Rapid Response Team
- Introduce structured pain rounds and pain champions
- Real-time PREM dashboard with daily alerts
5. Innovation & Learning
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| EHRS Utilization Rate (Full Entry) | 100% | 59% | -41% | Critical |
| Staff Participation in CME | >80% | 34% | -46% | Critical |
| Innovation Projects Initiated | >3/years | 0 | -3 | Critical |
Issues Identified:
- Minimal adoption of digital health tools
- No structured innovation program
- Staff disconnected from lifelong learning opportunities
Recommended Corrective Actions:
- Appoint Digital Transformation Lead
- Establish annual innovation fund and call for projects
- Partner with universities for CME pathways
Overall Ejada Performance Score: 38%
Status: Intensive Recovery Plan Required
Next Review Date: 1 June 2025
Final Recommendations:
- Appoint a full-time Ejada Recovery Officer
- Weekly reporting to the Ejada Oversight Authority
- Immediate strategic partnership with a high-performing hospital for mentorship
- Apply for emergency Ejada Recovery Grant to implement digital and quality initiatives
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