Indicator Performance
0.13
Benchmark
0.2
Infection
Multiple Drug Resistance Blood Stream Infection
MDRO
Preventing the Spread of Resistance: Strengthening Our Infection Control Culture
With an overall rate of 0.13 per 1,000 inpatient days, we remain well below the CDC benchmark of 0.2 — demonstrating the effectiveness of our robust infection prevention strategies and commitment to controlling antimicrobial resistance.
Indicator Performance
0.03
Benchmark
0.5
Infection
healthcare associated infection (HAI) Clostridium Difficile Infection (CDI)
HAI-CDI
Near-Zero Infection Rates: Sustaining Excellence in CDI Prevention
With a Clostridium difficile infection (CDI) rate of 0.03 per 1,000 inpatient days, we continue to exceed the CDC benchmark of 0.5 — reflecting our unwavering commitment to infection control and patient safety.
Indicator Performance
0.7
Benchmark
3.1
Embolism
Perioperative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT)
DVT
Exceeding National Standards: Ensuring Safer Surgical Outcomes
With a PE/DVT rate of 0.7 per 1,000 surgical discharges, we significantly outperform the AHRQ benchmark of 3.1 — highlighting our strong adherence to surgical safety protocols and excellence in postoperative care.
Indicator Performance
5%
Benchmark
10-15%
Readmission
30-day unplanned hospital readmission rate for medical and surgical patients
Readmission
Supporting Recovery Beyond Discharge
With an overall readmission rate of 5% per 100 adult discharges, we remain well within our internal goal of keeping readmissions below the 10% threshold — demonstrating our commitment to safe transitions of care and sustained recovery.
Indicator Performance
86%
Benchmark
90%
Access To Care
Hospital Wait at Point of Arrival (Minutes)
Waiting Time
Improving Access: Our Ongoing Commitment to Timely Care
In 2024, 86% of patients were seen within 60 minutes — closely aligning with the Department of Health (DOH) benchmark of 90%, reflecting our continuous efforts to enhance timely access to care.
Indicator Performance
97%
Benchmark
90%
Specialist Access
Consultant or specialist Hospital Appointment (excluding cancer) (Days)
Appointment
Timely Specialist Access: A System-Wide Success
In 2024, 97% of patients across the system were seen within 14 working days , significantly exceeding the Department of Health (DOH) benchmark of 90%.
Indicator Performance
81%
Benchmark
90%
Emergency Waiting Time
Seeing a doctor in Accident and Emergency (Minutes)
Emergency Time
Delivering Timely Emergency Care When It Matters Most
In 2024, 81% of patients were seen by a doctor within 60 minutes — a key focus area as we continue working toward meeting the Department of Health’s benchmark of 90% through targeted improvements and enhanced patient flow.
Indicator Performance
1%
Benchmark
3%
Re-Attendance
24 hours – Re attendance rate to Accident and Emergency Department
Emergency
Right Care the First Time: Reducing Unplanned Returns
With a re-attendance rate of just 1%, we remain well within our internal target of keeping unplanned returns below 3% — reinforcing our commitment to delivering effective and timely emergency care.
Indicator Performance
3%
Benchmark
3%
Incomplete Visit
Left Without Being Seen (LWBS) by an Emergency Department Doctor
LWBS
Keeping Patients Engaged in Their Emergency Care Journey
3% of patients left before being assessed — meeting Department of Health (DOH) of keeping this rate at or below 3%, as part of our ongoing efforts to ensure timely care and improve patient experience in the emergency department.
