Ejada Performance Intervention Report
Hospital Name: Zuleikha Hospital
Date: 22 March 2025
Reporting Authority: National Ejada Oversight Committee
Executive Summary:
Zuleikha Hospital has shown systemic performance challenges across key Ejada domains, with a cumulative score of 44%. This report outlines observed underperformance in clinical quality, patient flow, digital adoption, and patient-reported outcomes. Comprehensive remedial strategies are proposed to support hospital leadership in implementing sustainable improvements.
1. Clinical Excellence
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| 30-day Readmission Rate | <10% | 20.1% | +10.1% | Critical |
| Surgical Site Infection Rate | <1.5% | 2.9% | +1.4% | Underperforming |
| Antimicrobial Stewardship Compliance | >90% | 58% | -32% | Critical |
| Unplanned ICU Transfers | <5% | 9.6% | +4.6% | Critical |
Issues Identified:
- Lack of protocolized care in high-risk areas
- Insufficient clinical audit and review practices
Recommended Corrective Actions:
- Implement early warning score system hospital-wide
- Establish real-time quality dashboard for infection and ICU alerts
2. Operational Efficiency
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| ED Waiting Time (mins) | <45 | 101 | +56 | Critical |
| Average LOS (days) | 4.0 | 6.1 | +2.1 | Underperforming |
| Bed Turnover Rate | >3.5 | 2.1 | -1.4 | Underperforming |
| Discharge Summary Issued <24h | >95% | 68% | -27% | Underperforming |
Issues Identified:
- Delays in discharge summary preparation
- Limited hospitalist involvement in LOS management
Recommended Corrective Actions:
- Implement automated discharge summary templates
- Daily bed management huddles led by medical officers
3. Financial Sustainability
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| Claims Rejection Rate | <5% | 13% | +8% | Critical |
| Documentation Completeness | >95% | 70% | -25% | Underperforming |
| Unbilled Encounters Rate | <1% | 4.7% | +3.7% | Critical |
Issues Identified:
- Lack of internal audits on claims
- Fragmented coordination between coding and clinical teams
Recommended Corrective Actions:
- Launch daily coding-clinical validation rounds
- Assign documentation champions in each department
4. Patient Experience
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| Overall Patient Satisfaction | >85% | 58% | -27% | Critical |
| Staff Courtesy (PREM Domain) | >90% | 67% | -23% | Underperforming |
| Noise Level at Night (HCAHPS) | <10% complaints | 29% | +19% | Underperforming |
| Mobility Improvement Rate (PROM) | >85% | 57% | -28% | Underperforming |
| Understanding of Medication Side Effects (PREM) | >90% | 61% | -29% | Critical |
Issues Identified:
- Poor patient education processes
- Lack of environmental control during rest hours
Recommended Corrective Actions:
- Deploy bedside education program via tablets
- Establish 'Quiet Hours' with hourly rounding protocol
5. Innovation & Learning
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| EHR Utilization Rate (Full Entry) | 100% | 66% | -34% | Underperforming |
| Staff Participation in CME | >80% | 48% | -32% | Underperforming |
| Innovation Activities per Quarter | >3 | 1 | -2 | Underperforming |
Issues Identified:
- Limited institutional focus on innovation
- No structured pathway for CME engagement
Recommended Corrective Actions:
- Introduce monthly clinical innovation webinars
- Partner with DHA to pilot EHR smart modules
Overall Ejada Performance Score: 44%
Status: Structured Performance Recovery Plan Required
Next Review Date: 1 June 2025
Final Recommendations:
- Create multidisciplinary Ejada taskforce to monitor progress
- Initiate monthly external quality review visits
- Apply for EHR capability maturity model upgrade with Ejada Innovation Unit
- Link executive bonuses to pillar-based recovery metrics
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