Ejada Performance Intervention Report
Hospital Name: Aster Hospital
Date: 22 March 2025
Reporting Authority: National Ejada Oversight Committee
Executive Summary:
Aster Hospital has shown significant variability in performance across Ejada domains. While operational and financial domains demonstrate moderate performance, clinical outcomes and patient experience indicators remain below acceptable thresholds. With an overall Ejada score of 49%, targeted intervention is recommended to prevent further decline and ensure continuous improvement.
1. Clinical Excellence
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| 30-day Readmission Rate | <10% | 17.8% | +7.8% | Underperforming |
| Surgical Site Infection Rate | <1.5% | 2.5% | +1.0% | Underperforming |
| Antimicrobial Stewardship Compliance | >90% | 69% | -21% | Underperforming |
| Inpatient Fall Rate | <2 per 1,000 pt days | 3.2 | +1.2 | Critical |
Issues Identified:
- Suboptimal medication safety and infection control
- Reactive rather than proactive quality monitoring
Recommended Corrective Actions:
- Conduct root cause analysis for inpatient falls
- Weekly infection control rounds
- Introduce physician prescribing feedback system
2. Operational Efficiency
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| ED Waiting Time (mins) | <45 | 78 | +33 | Underperforming |
| Average LOS (days) | 4.0 | 5.6 | +1.6 | Underperforming |
| OR Utilization Rate | >80% | 63% | -17% | Underperforming |
| Time to Triage in ED | <10 mins | 18 mins | +8 | Critical |
Issues Identified:
- Lack of automated patient flow tracking tools
- Delayed triage initiation during peak hours
Recommended Corrective Actions:
- Deploy patient flow management system in ED
- Redesign triage process with dedicated team during rush hours
3. Financial Sustainability
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| Claims Rejection Rate | <5% | 9% | +4% | Underperforming |
| Billing Accuracy Rate | >98% | 86% | -12% | Underperforming |
| Revenue Leakage Identified | <1% | 3.2% | +2.2% | Critical |
Issues Identified:
- Manual billing prone to omissions
- Fragmented pre-authorization process
Recommended Corrective Actions:
- Integrate claims pre-check module with EHR
- Assign revenue cycle managers in each clinical service line
4. Patient Experience
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| Overall Patient Satisfaction | >85% | 66% | -19% | Underperforming |
| Staff Courtesy (PREM Domain) | >90% | 73% | -17% | Underperforming |
| Noise Level at Night (HCAHPS) | <10% complaints | 24% | +14% | Underperforming |
| Functional Status Improvement (PROM) | >85% | 62% | -23% | Underperforming |
| Understanding of Treatment Plan (PREM) | >90% | 70% | -20% | Underperforming |
Issues Identified:
- Gaps in patient engagement and education
- No formal noise reduction strategy in wards
Recommended Corrective Actions:
- Establish a dedicated Patient Education Team
- Launch ‘Quiet Zone’ ward policy with patient alerts
5. Innovation & Learning
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| EHR Utilization Rate (Full Entry) | 100% | 81% | -19% | Underperforming |
| Staff Participation in CME | >80% | 52% | -28% | Underperforming |
| Internal Process Innovation Projects | >3 | 2 | -1 | Underperforming |
Issues Identified:
- Limited incentivization for innovation
- No structured CME completion tracking
Recommended Corrective Actions:
- Introduce CME point-based reward system
- Host quarterly innovation showcase for departments
Overall Ejada Performance Score: 49%
Status: Performance Support Plan Required
Next Review Date: 1 July 2025
Final Recommendations:
- Appoint Ejada Domain Leads to drive improvement per pillar
- Conduct external review with DHA quality consultants
- Begin use of KPI visualization tools to engage staff
- Link department performance to quarterly quality incentives
Chat with EJADA
How can I help you today?