Ejada Performance Intervention Report
Hospital Name: American Hospital
Date: 22 March 2025
Reporting Authority: National Ejada Oversight Committee
Executive Summary:
American Hospital has achieved high performance across all five Ejada pillars, with an overall score of 89%. The facility demonstrates particular excellence in patient experience, financial sustainability, and innovation. This report highlights outstanding practices, strong governance, and national leadership potential as an Ejada Centre of Excellence.
1. Clinical Excellence
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| 30-day Readmission Rate | <10% | 7.4% | -2.6% | Achieved |
| Surgical Site Infection Rate | <1.5% | 1.1% | -0.4% | Achieved |
| Antimicrobial Stewardship Compliance | >90% | 94% | +4% | Achieved |
| Unplanned ICU Transfers | <5% | 3.1% | -1.9% | Achieved |
Issues Identified:
- Strong clinical governance and monitoring
- High compliance with evidence-based pathways
Recommended Corrective Actions:
- Mentor hospitals on ICU escalation protocols and readmission prevention
2. Operational Efficiency
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| ED Waiting Time (mins) | <45 | 35 | -10 | Achieved |
| Average LOS (days) | 4.0 | 3.9 | -0.1 | Achieved |
| OR Utilization Rate | >80% | 84% | +4% | Achieved |
| Discharge Summary Issued <24h | >95% | 98% | +3% | Exceeded |
Issues Identified:
- Integrated EHR with discharge and flow optimization tools
- OR productivity tracked in real-time
Recommended Corrective Actions:
- Showcase digital discharge tools and real-time OR dashboards
3. Financial Sustainability
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| Claims Rejection Rate | <5% | 3.1% | -1.9% | Achieved |
| Billing Accuracy Rate | >98% | 98.9% | +0.9% | Achieved |
| Revenue Cycle Turnaround Time | <30 days | 20 days | -10 | Exceeded |
Issues Identified:
- Mature revenue integrity system in place
- Minimal manual errors in billing and coding
Recommended Corrective Actions:
- Host DHA billing accuracy workshops
4. Patient Experience
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| Overall Patient Satisfaction | >85% | 92% | +7% | Exceeded |
| Staff Courtesy (PREM Domain) | >90% | 94% | +4% | Achieved |
| Noise Level at Night (HCAHPS) | <10% complaints | 5% | -5% | Achieved |
| PROM: Functional Recovery | >85% | 88% | +3% | Achieved |
| Understanding of Discharge Instructions (PREM) | >90% | 95% | +5% | Exceeded |
Issues Identified:
- High-touch service culture and staff-patient engagement
- Technology-enhanced education and follow-up
Recommended Corrective Actions:
- Share PREM and PROM integration strategies nationally
5. Innovation & Learning
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| EHR Utilization Rate (Full Entry) | 100% | 100% | 0% | Achieved |
| Staff Participation in CME | >80% | 92% | +12% | Exceeded |
| Innovation Projects Initiated | >3 | 5 | +2 | Exceeded |
Issues Identified:
- AI-enabled diagnostics and predictive tools in active use
- Continuous innovation rounds led by executive leadership
Recommended Corrective Actions:
- Partner with Ejada to pilot patient-centered AI tools
Overall Ejada Performance Score: 89%
Status: Recognized High-Performer
Next Review Date: March 2026
Final Recommendations:
- Participate in Ejada-led innovation consortiums
- Serve as benchmarking host site for patient experience and AI deployment
- Document case studies for Ejada learning network
- Support digital maturity assessments across peer facilities
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