Accreditation Quality Report

Transcription

1 Accreditation Quality Report Version: 10 Date: 4/14/2011

2 Welcome to the Joint Commission's Quality Report. We know how important reliable information is to you and your family when making health care decisions. This Quality Report will help you make the right decisions to meet your needs. Since 1951, the Joint Commission has been the national leader in setting standards for health care organizations. When a health care organization seeks accreditation, it demonstrates commitment to giving safe, high quality health care and to continually working to improve that care. The Quality Report is only one way to determine whether a health care organization can meet your needs. Discuss this report with your doctor or with other professional acquaintances before making a care decision. In addition to the accreditation status of the organization, the Quality Report uses checks, pluses, and minuses in each of the following key areas to help you compare a health care organization with similar accredited organizations. National Patient Safety Goals - safety guidelines that target the prevention of medical errors such as surgery on the wrong side of the body and safe medication use. National Quality Improvement Goals - measures the care of patients with specific conditions such as heart failure or pregnancy. Not all measures are relevant to or available for all types of health care organizations. The Joint Commission will add relevant measures of health care quality as more measures become available. Your comments are just as important to us. The content and format of the Quality Report will be updated from time to time based on changes in the health care industry and your suggestions. Please call Customer Service at or the Joint Commission at qualityreport@jointcommission.org with your comments and suggestions. Mark R. Chassin, MD, MPP, MPH President of the Joint Commission

3 Summary of Quality Information Symbol Key This organization achieved the best possible results. above the target range/value. similar to the target range/value. below the target range/value. This Measure is not applicable for this organization. Not displayed Footnote Key The Measure or Measure Set was not reported. The Measure Set does not have an overall result. The number of patients is not enough for comparison purposes. The measure meets the Privacy Disclosure Threshold rule. The organization scored above 90% but was below most other organizations. The Measure results are not statistically valid. The Measure results are based on a sample of patients. The number of months with Measure data is below the reporting requirement. The measure results are temporarily suppressed pending resubmission of updated data. Accreditation Programs Accreditation Decision Effective Last Full Survey Last On-Site Date Date Survey Date Home Care Accredited 1/14/2011 1/13/2011 1/13/2011 Accredited 1/14/2011 1/13/2011 1/13/2011 Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS) Other Accredited Programs/Services ( Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)) Special Quality Awards 2008 Magnet Award Home Care Reporting Period: Oct Sep National Patient Safety Goals 2008National Patient Safety Goals National Quality Improvement Goals: Heart Attack Care Heart Failure Care Pneumonia Care Surgical Care Improvement Project (SCIP) SCIP - Cardiac SCIP - Infection Prevention For All Reported Procedures: Blood Vessel Surgery Compared to other Joint Commission Accredited Organizations Nationwide Statewide * * Colon/Large Intestine Surgery Hip Joint Replacement Hysterectomy Knee Replacement SCIP Venous Thromboembolism (VTE) s voluntarily participate in the Survey of Experiences (HCAHPS). Pediatric and psychiatric hospitals are not eligible to participate in the HCAHPS survey based on their patient population. 3 Copyright 2011, The Joint Commission

4 Locations of Care * Primary Location Locations of Care Center for Occupational Medicine 1248 Kinneys Lane Portsmouth, OH Home Care of Southern Ohio 724 8th Street Portsmouth, OH Lucasville Rehab Center Route 23 Lucasville, OH Michael E. Martin, M.D th Street Portsmouth, OH SOMC Anticoagulation Clinic 1248 Kinneys Lane Portsmouth, OH SOMC Ear, Nose & Throat Associates th Street Braulin Suite 403 Portsmouth, OH SOMC Heart and Vascular Associates th Street Braulin Building Suite Portsmouth, OH SOMC Hospice th Street Portsmouth, OH SOMC Hospice Center th Street Portsmouth, OH Available Services Single Specialty Practitioner ( Bereavement Care Community Bereavement Care Family of Home Health, Non-Hospice Services Nutrition Occupational Therapy Palliative Care General Outpatient Services ( Single Specialty Practitioner ( Coagulopathy Treatment ( General Outpatient Services ( Physical Therapy Social Work Speech Therapy Telehealth Wound Care Single Specialty Group Practice ( Atrial Fibrillation ( Carotid Stenosis ( Coronary Artery Disease ( Diabetes Mellitus ( Health and Wellness ( Heart Failure ( Bereavement Care Community Bereavement Care Family of Hospice Care Palliative Care Bereavement Care Community Bereavement Care Family of Hospice Care Inpatient Symptom Relief Palliative Care Hyperlipidemia ( Hypertension ( Ischemic Heart Disease ( Single Specialty Group Practice ( Vascular Disease ( 4 Copyright 2011, The Joint Commission

5 Locations of Care * Primary Location Locations of Care SOMC Lucasville Primary Care 10 Thomas Hollow Road Lucasville, OH Arthritis ( Asthma ( Asthma, Pediatrics ( Coronary Artery Disease ( Depression ( Diabetes Mellitus ( Emphysema ( Available Services Health and Wellness ( Hyperlipidemia ( Hypertension ( Low Back Pain ( Pneumonia ( Single Specialty Practitioner ( Vascular Disease ( SOMC Minford Family Practice 8792 Stte Route 335 Minford, OH Arthritis ( Asthma ( Asthma, Pediatrics ( Depression ( Diabetes Mellitus ( Health and Wellness ( Heart Failure ( Hypertension ( Low Back Pain ( Pneumonia ( Single Specialty Practitioner ( Vascular Disease ( SOMC Orthopedic Associates th Street Fulton Suite 304 Portsmouth, OH SOMC Physical Medicine and Rehabilitation 613 Center Street Wheelersburg, OH SOMC Physician Specialty Group th Street, Bld. C Suite 102 Portsmouth, OH SOMC Portsmouth Family Practice 1835 Oakland Ave Portsmouth, OH SOMC Psychiatry th Street Building C, Suite 201 Portsmouth, OH SOMc Pulmonary and Critical Care Associates th Street Waller Suite 108 Portsmouth, OH SOMC Rehabilitation Services 1248 Kinneys Lane Portsmouth, OH Single Specialty Practitioner ( Single Specialty Practitioner ( Epilepsy ( Hepatitis B/C ( HIV/AIDS ( Hypertension ( Single Specialty Practitioner ( Anxiety/panic disorders ( Attention Deficit Disorder ( Bipolar disorder ( Depression ( Single Specialty Group Practice ( General Outpatient Services ( Multi Specialty Group Practice ( Multiple Sclerosis ( Tuberculosis ( Vascular Disease ( Schizophrenia ( Self Injury ( Single Specialty Group Practice ( 5 Copyright 2011, The Joint Commission

6 Locations of Care * Primary Location Locations of Care SOMC Sciotoville Family Practice 5611 Gallia Street Portsmouth, OH SOMC Sleep Lab th Street Portsmouth, OH SOMC Surgical Associates th Street Braulin Suite 402 Portsmouth, OH SOMC Urgent Care 8770 Ohio River Road Wheelersburg, OH SOMC Urgent Care Center-Portsmouth 1248 Kinneys Lane Portsmouth, OH SOMC Vanceburg Family Practice and Specialty Associates 207 Plummers Lane Vanceburg, KY SOMC Wheelersburg Family Practice 613 Center Street Wheelersburg, OH SOMC Wheelersburg Rehab Services 613 Center Street Wheelersburg, OH SOMC Wound Healing Center th Street Portsmouth, OH Arthritis ( Asthma ( Asthma, Pediatrics ( Diabetes Mellitus ( Emphysema ( Health and Wellness ( Available Services General Outpatient Services ( Sleeping Disorder ( Multi Specialty Group Practice ( General Outpatient Services ( General Outpatient Services ( Multi Specialty Group Practice ( Single Specialty Practitioner ( General Outpatient Services ( General Outpatient Services ( Heart Failure ( Hypertension ( Low Back Pain ( Pneumonia ( Single Specialty Group Practice ( 6 Copyright 2011, The Joint Commission

7 Locations of Care * Primary Location Locations of Care Southern Ohio Medical Center (Main Campus) * th Street Portsmouth, OH Abdominal Aortic Aneurysm (Inpatient) Acute Coronary Syndrome (Inpatient, Acute Myocardial Infarction (Inpatient) Allergy ( Amyotrophic Lateral Sclerosis (Inpatient, Anxiety/panic disorders ( Arthritis (Inpatient, Asthma (Inpatient, Asthma, Pediatrics (Inpatient, Atrial Fibrillation (Inpatient, Attention Deficit Disorder ( Audiology (Inpatient, Benign prostatic hyperplasia (BPH) (Inpatient, Bipolar disorder ( Brain Injury Rehabilitation (Inpatient, Outpatient, 24-hour Acute Care/Crisis Stabilization) Breast Cancer (Inpatient, Burn Treatment (Inpatient, Cancer Center/Oncology (Inpatient, Cardiac Catheterization Lab (Inpatient, Cardiac Rehabilitation ( Cardiac Surgery (Inpatient, Cardiac Unit/Cardiology (Inpatient, Carotid Stenosis (Inpatient, Cellulitis (Inpatient, Chronic Kidney Disease (Inpatient, Chronic Obstructive Pulmonary Disease (Inpatient, Coagulopathy Treatment (Inpatient, Colon/Rectal Cancer (Inpatient, Available Services Ischemic Heart Disease (Inpatient, Joint Replacement - Knee (Inpatient) Joint Replacement - Shoulder (Inpatient) Labor & Delivery (Inpatient) Leukemia (Inpatient, Lithotripsy/Kidney Stone Treatment (Inpatient, Liver Diseases (Inpatient, Low Back Pain (Inpatient, Lung Cancer (Inpatient, Magnetic Resonance Imaging (Inpatient, Maternal Child (Inpatient, Medical Detoxification (Inpatient) Mental Health ( Multiple Sclerosis (Inpatient, Nephrology (Inpatient, Neurology (Inpatient, Nuclear Medicine (Inpatient, Nursery (Inpatient) Nutrition Programs (Inpatient, Obstetrics (Inpatient, Occupational Health ( Operating Room (Inpatient, Ophthalmology/Eye Surgery (Inpatient, Oral Maxillofacial Surgery (Inpatient, Orthopedic Surgery (Inpatient, Osgood-Schlatter (Inpatient, Osteopathic Care (Inpatient, Osteoporosis (Inpatient, Otolaryngology/Ear, Nose, and Throat (Inpatient, Outpatient Surgery ( 7 Copyright 2011, The Joint Commission

8 Locations of Care * Primary Location Locations of Care Coronary Artery Bypass Graft (Inpatient) Coronary Artery Disease (Inpatient, Crohn's Disease (Inpatient, CT Scanner (Inpatient, Dentistry ( Depression ( Dermatology (Inpatient, Developmental Disabilities - ( Diabetes Mellitus (Inpatient, Dialysis (Inpatient, Eating Disorders ( EEG/EKG/EMG Lab (Inpatient, Electroconvulsive Therapy ( Emergency Room ( Emphysema (Inpatient, End Stage Renal Disease (Inpatient) Endocrinology (Inpatient, Epilepsy (Inpatient, Esophageal Cancer (Inpatient, Family Practice (Inpatient, Gastroenterology (Inpatient, Gastroesophageal Reflux Disease (Inpatient, General Medical Services (Inpatient, General Surgery (Inpatient, GI or Endoscopy Lab (Inpatient, Gynecology (Inpatient, Health and Wellness (Inpatient, Heart Failure (Inpatient, Hematology/Blood Treatment (Inpatient, Hemophilia (Inpatient, Available Services Pain Management (Inpatient, Pancreatic Cancer (Inpatient, Pancreatitis (Inpatient, Parkinsons Disease (Inpatient, Pathology (Inpatient, Pediatric Care (Inpatient, Pelvic Inflammatory Disease (Inpatient, Perimenopause (Inpatient, Peripheral Vascular Disease (Inpatient, Plastic Surgery (Inpatient, Pneumonia (Inpatient, Podiatry (Inpatient, Post Anesthesia Care Unit (PACU) (Inpatient, Prostate Cancer (Inpatient, Pulmonary Function Lab (Inpatient, Radiation Oncology ( Rehabilitation and Physical Medicine (Inpatient, Respiratory Care (Ventilator) (Inpatient) Respiratory Failure (Inpatient) Respite Care (Inpatient) Rheumatology (Inpatient, Schizophrenia ( Self Injury (Inpatient, Sexually Transmitted Disease (Inpatient, Sleep Center ( Sleeping Disorder (Inpatient, Spine Care ( Sports Medicine ( Stroke Rehabilitation (Inpatient, Subacute Care (Inpatient) Systemic Lupus Erythematosis (Inpatient, Telemetry (Inpatient) Thoracic Surgery (Inpatient, 8 Copyright 2011, The Joint Commission

9 Locations of Care * Primary Location Locations of Care Hepatitis B/C (Inpatient, Hip Joint Replacement (Inpatient) HIV/AIDS (Inpatient, Hodgkin's disease (Inpatient, Hyperbilirubinemia (Inpatient, Hyperlipidemia (Inpatient, Hypertension (Inpatient, Hyperthyroidism/Hypothyroidi sm (Inpatient, Imaging/Radiology (Inpatient, Infectious Diseases (Inpatient, Infertility (Inpatient, Infusion Therapy (Inpatient, Inpatient Diabetes (Inpatient) Intensive Care Unit (Inpatient) Internal Medicine (Inpatient, Interventional Cardiac Catheterization (Inpatient, Interventional Radiology (Inpatient, Irritable Bowel Syndrome (Inpatient, Available Services Tobacco Treatment / Cessation (Inpatient, Traumatic Brain Injury (Inpatient) Tuberculosis (Inpatient, Ulcerative Colitis (Inpatient, Ultrasound (Inpatient, Urgent Care/Emergency Medicine ( Urology (Inpatient, Vascular Disease (Inpatient, Vascular Surgery (Inpatient, Weight Loss (Inpatient, Women's Health (Inpatient, Wound Care (Inpatient, Southern Ohio Medical Center Cancer Center 1121 Kinneys Lane Portsmouth, OH Breast Cancer ( Esophageal Cancer ( Hodgkin's disease ( Leukemia ( Lung Cancer ( Multi Specialty Group Practice ( Pancreatic Cancer ( Prostate Cancer ( 9 Copyright 2011, The Joint Commission

10 2008 National Patient Safety Goals Symbol Key The organization has met the National Patient Safety Goal. The organization has not met the National Patient Safety Goal. The Goal is not applicable for this organization. Home Care Safety Goals Organizations Should Implemented Improve the accuracy of patient identification. Improve the effectiveness of communication among caregivers. Use at least two patient identifiers when providing care, treatment or services. Prior to the start of any surgical or invasive procedure, conduct a final verification process, (such as a time out, ) to confirm the correct patient, procedure and site using active not passive communication techniques. For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result. Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. Implement a standardized approach to hand off communications, including an opportunity to ask and respond to questions. Improve the safety of using medications. Reduce the risk of health care-associated infections. Accurately and completely reconcile medications across the continuum of care. Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. Comply with current World Health Organization (WHO) Hand Hygiene Guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection. There is a process for comparing the patient s current medications with those ordered for the patient while under the care of the organization. A complete list of the patient s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the organization. Reduce the risk of patient harm resulting from falls. Encourage patients active involvement in their own care as a patient safety strategy. Implement a fall reduction program including an evaluation of the effectiveness of the program. Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so. 10 Copyright 2011, The Joint Commission

11 2008 National Patient Safety Goals Symbol Key The organization has met the National Patient Safety Goal. The organization has not met the National Patient Safety Goal. The Goal is not applicable for this organization. Home Care Safety Goals Organizations Should Implemented The organization identifies safety risks inherent in its patient population. The organization identifies risks associated with long-term oxygen therapy such as home fires. 11 Copyright 2011, The Joint Commission

12 2008 National Patient Safety Goals Symbol Key The organization has met the National Patient Safety Goal. The organization has not met the National Patient Safety Goal. The Goal is not applicable for this organization. Safety Goals Organizations Should Implemented Improve the accuracy of patient identification. Use at least two patient identifiers when providing care, treatment or services. Improve the effectiveness of communication among caregivers. Improve the safety of using medications. Reduce the risk of health care-associated infections. Accurately and completely reconcile medications across the continuum of care. Reduce the risk of patient harm resulting from falls. Encourage patients active involvement in their own care as a patient safety strategy. The organization identifies safety risks inherent in its patient population. For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result. Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. Measure and assess, and if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. Implement a standardized approach to hand off communications, including an opportunity to ask and respond to questions. Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field. Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. Comply with current World Health Organization (WHO) Hand Hygiene Guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection. There is a process for comparing the patient s current medications with those ordered for the patient while under the care of the organization. A complete list of the patient s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility. Implement a fall reduction program including an evaluation of the effectiveness of the program. Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so. The organization identifies patients at risk for suicide. [Applicable to psychiatric hospitals and patients being treated for 12 Copyright 2011, The Joint Commission

13 2008 National Patient Safety Goals Symbol Key The organization has met the National Patient Safety Goal. The organization has not met the National Patient Safety Goal. The Goal is not applicable for this organization. Safety Goals Organizations Should Implemented emotional or behavioral disorders in general hospitals --NOT APPLICABLE TO CRITICAL ACCESS HOSPITALS] Improve recognition and response to changes in a patient s condition. Universal Protocol The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient s condition appears to be worsening. [Critical Access, ] Conduct a pre-operative verification process. Mark the operative site. Conduct a "time out" immediately before starting the procedure. 13 Copyright 2011, The Joint Commission

14 National Quality Improvement Goals Symbol Key This organization achieved the best possible results above the target range/value. similar to the target range/value. below the target range/value. Not displayed Footnote Key The Measure or Measure Set was not reported. The Measure Set does not have an overall result. The number of patients is not enough for comparison purposes. The measure meets the Privacy Disclosure Threshold rule. The organization scored above 90% but was below most other organizations. The Measure results are not statistically valid. The Measure results are based on a sample of patients. The number of months with Measure data is below the reporting requirement. The measure results are temporarily suppressed pending resubmission of updated data. ACE inhibitor or ARB for LVSD* Adult smoking cessation advice/counseling* Aspirin at arrival* Measure Explanation Results Heart attack patients who receive either a prescription for a medicine called an ACE inhibitor or a medicine called an angiotensin receptor blocker (ARB) when they are discharged from the hospital. This measure reports what percent of heart attack patients who have problems with the heart pumping enough blood to the body were prescribed medicines to improve the heart s ability to pump blood. Heart attack patients who are given advice about stopping smoking while they are in the hospital. This measure reports what percent of adult heart attack patients are provided advice and/or counseling to quit smoking. Smoking harms the heart, lungs and blood vessels and makes existing heart disease worse. Limitations of measure use - see Accreditation Quality Report User Guide. Heart attack patients receiving aspirin when arriving at the hospital. This measure reports what percent of heart attack patients receive aspirin within 24 hours before or after they arrive at the hospital. Aspirin is beneficial because it reduces the tendency of blood to clot in blood vessels of the heart and improves survival rates. Compared to other Joint Commission Measure Area Explanation Nationwide Statewide Heart Attack Care This category of evidence based measures assesses the overall quality of care provided to Heart Attack (AMI) patients. of 34 eligible of 72 eligible of 190 eligible Compared to other Joint Commission Nationwide Statewide Top 10% Top 10% Scored : Scored : * This information is part of the Quality Alliance. This information can also be viewed at 14 Copyright 2011, The Joint Commission

15 National Quality Improvement Goals Symbol Key This organization achieved the best possible results above the target range/value. similar to the target range/value. below the target range/value. Not displayed Footnote Key The Measure or Measure Set was not reported. The Measure Set does not have an overall result. The number of patients is not enough for comparison purposes. The measure meets the Privacy Disclosure Threshold rule. The organization scored above 90% but was below most other organizations. The Measure results are not statistically valid. The Measure results are based on a sample of patients. The number of months with Measure data is below the reporting requirement. The measure results are temporarily suppressed pending resubmission of updated data. Aspirin prescribed at discharge* Measure Explanation Results Beta blocker prescribed at discharge* Heart attack patients who receive a prescription for aspirin when being discharged from the hospital. This measure reports how often aspirin was prescribed to heart attack patients when they are leaving a hospital. Aspirin is beneficial because it reduces the tendency of blood to clot in blood vessels of the heart and improves survival rates. Heart attack patients who have a medicine called a "beta blocker" prescribed when they are discharged from the hospital. This measure reports what percent of heart attack patients were prescribed a special type of medicine when leaving the hospital, that has been shown to reduce further heart damage. Compared to other Joint Commission Measure Area Explanation Nationwide Statewide Heart Attack Care This category of evidence based measures assesses the overall quality of care provided to Heart Attack (AMI) patients. of 166 eligible of 175 eligible * This information is part of the Quality Alliance. This information can also be viewed at Compared to other Joint Commission Nationwide Statewide Top 10% Top 10% Scored : Scored : 15 Copyright 2011, The Joint Commission

16 National Quality Improvement Goals Symbol Key This organization achieved the best possible results above the target range/value. similar to the target range/value. below the target range/value. Not displayed Footnote Key The Measure or Measure Set was not reported. The Measure Set does not have an overall result. The number of patients is not enough for comparison purposes. The measure meets the Privacy Disclosure Threshold rule. The organization scored above 90% but was below most other organizations. The Measure results are not statistically valid. The Measure results are based on a sample of patients. The number of months with Measure data is below the reporting requirement. The measure results are temporarily suppressed pending resubmission of updated data. Measure Explanation Results Fibrinolytic therapy received within 30 minutes of hospital arrival* Heart attack patients who receive a medicine that breaks up blood clots (fibrinolytic therapy) within 30 minutes of hospital arrival. This measure reports how quickly heart attack patients were given a medication that breaks up blood clots (fibrinolytic therapy). Breaking up blood clots increases blood flow to the heart. If blood flow is returned to the heart muscle quickly during a heart attack, the risk of death is decreased. The medicine that breaks up clots in the arteries and allows the return of normal blood flow is called fibrinolytic therapy and is used in certain types of heart attacks. It is important that this medicine be given quickly after a heart attack is diagnosed. Compared to other Joint Commission Measure Area Explanation Nationwide Statewide Heart Attack Care This category of evidence based measures assesses the overall quality of care provided to Heart Attack (AMI) patients. * This information is part of the Quality Alliance. This information can also be viewed at ---- Compared to other Joint Commission Nationwide Statewide Top 10% Top 10% Scored : Scored 3 : 60% Copyright 2011, The Joint Commission

17 National Quality Improvement Goals - Quarterly Results Heart Attack Care ACE inhibitor or ARB for LVSD* % Nationwide Adult smoking cessation advice/counseling* Nationwide Aspirin at arrival* Nationwide Aspirin prescribed at discharge* Nationwide * This information is part of the Quality Alliance. This information can also be viewed at *** The measure was not in effect for this quarter. 1 - The measure or measure set was not reported. 3 - The number of patients is not enough for comparison purposes. 4 - The measure meets the Privacy Disclosure Threshold rule. 7 - The measure results are based on a sample of patients. 8 - The number of months with measure data is below the reporting requirement. 17 Copyright 2011, The Joint Commission

18 National Quality Improvement Goals - Quarterly Results Heart Attack Care Beta blocker prescribed at discharge* Nationwide Fibrinolytic therapy received within 30 minutes of hospital arrival* No Quarterly Results are available * This information is part of the Quality Alliance. This information can also be viewed at *** The measure was not in effect for this quarter. 1 - The measure or measure set was not reported. 3 - The number of patients is not enough for comparison purposes. 4 - The measure meets the Privacy Disclosure Threshold rule. 7 - The measure results are based on a sample of patients. 8 - The number of months with measure data is below the reporting requirement. 18 Copyright 2011, The Joint Commission

19 National Quality Improvement Goals Symbol Key This organization achieved the best possible results above the target range/value. similar to the target range/value. below the target range/value. Not displayed Footnote Key The Measure or Measure Set was not reported. The Measure Set does not have an overall result. The number of patients is not enough for comparison purposes. The measure meets the Privacy Disclosure Threshold rule. The organization scored above 90% but was below most other organizations. The Measure results are not statistically valid. The Measure results are based on a sample of patients. The number of months with Measure data is below the reporting requirement. The measure results are temporarily suppressed pending resubmission of updated data. Measure Explanation Results ACE inhibitor or ARB for LVSD* Adult smoking cessation advice/counseling* Discharge instructions* Heart failure patients who receive either a prescription for a medicine called an ACE inhibitor or a medicine called an angiotensin receptor blocker (ARB) when they are discharged from the hospital. This measure reports what percent of heart failure patients who have problems with the heart pumping enough blood to the body were prescribed medicines to improve the heart s ability to pump blood. Heart failure patients who are given advice about stopping smoking while they are in the hospital. This measure reports what percent of adult heart failure patients are provided advice and/or counseling to quit smoking. Smoking harms the heart, lungs and blood vessels and makes existing heart disease worse. Limitations of measure use - see Accreditation Quality Report User Guide. Heart failure patients who receive specific discharge instructions about their condition. This measure reports what percent of patients with heart failure are given information about their condition and care when they leave the hospital. Patient education about medicines, diet, activities, and signs to watch for is important in order to prevent further hospitalization. Limitations of measure use - see Accreditation Quality Report User Guide. Compared to other Joint Commission Measure Area Explanation Nationwide Statewide Heart Failure Care This category of evidence based measures assesses the overall quality of care provided to Heart Failure (HF) patients. of 111 eligible of 69 eligible of 302 eligible Compared to other Joint Commission Nationwide Statewide Top 10% Top 10% Scored : Scored : 90% 92% * This information is part of the Quality Alliance. This information can also be viewed at 19 Copyright 2011, The Joint Commission

20 National Quality Improvement Goals Symbol Key This organization achieved the best possible results above the target range/value. similar to the target range/value. below the target range/value. Not displayed Footnote Key The Measure or Measure Set was not reported. The Measure Set does not have an overall result. The number of patients is not enough for comparison purposes. The measure meets the Privacy Disclosure Threshold rule. The organization scored above 90% but was below most other organizations. The Measure results are not statistically valid. The Measure results are based on a sample of patients. The number of months with Measure data is below the reporting requirement. The measure results are temporarily suppressed pending resubmission of updated data. LVF assessment* Measure Explanation Results Heart failure patients who have had the function of the main pumping chamber of the heart (i.e., left ventricle) checked during their hospitalization. This measure reports what percent of patients with heart failure receive an in-depth evaluation of heart muscle function in order to get the right treatment for their heart failure. Limitations of measure use - see Accreditation Quality Report User Guide. Compared to other Joint Commission Measure Area Explanation Nationwide Statewide Heart Failure Care This category of evidence based measures assesses the overall quality of care provided to Heart Failure (HF) patients. of 390 eligible * This information is part of the Quality Alliance. This information can also be viewed at Compared to other Joint Commission Nationwide Statewide Top 10% Top 10% Scored : Scored : 20 Copyright 2011, The Joint Commission

21 National Quality Improvement Goals - Quarterly Results Heart Failure Care ACE inhibitor or ARB for LVSD* Nationwide Adult smoking cessation advice/counseling* Nationwide Discharge instructions* Nationwide 89% 90% 91% 91% LVF assessment* Nationwide * This information is part of the Quality Alliance. This information can also be viewed at *** The measure was not in effect for this quarter. 1 - The measure or measure set was not reported. 3 - The number of patients is not enough for comparison purposes. 4 - The measure meets the Privacy Disclosure Threshold rule. 7 - The measure results are based on a sample of patients. 8 - The number of months with measure data is below the reporting requirement. 21 Copyright 2011, The Joint Commission

22 National Quality Improvement Goals Symbol Key This organization achieved the best possible results above the target range/value. similar to the target range/value. below the target range/value. Not displayed Footnote Key The Measure or Measure Set was not reported. The Measure Set does not have an overall result. The number of patients is not enough for comparison purposes. The measure meets the Privacy Disclosure Threshold rule. The organization scored above 90% but was below most other organizations. The Measure results are not statistically valid. The Measure results are based on a sample of patients. The number of months with Measure data is below the reporting requirement. The measure results are temporarily suppressed pending resubmission of updated data. Measure Explanation Results Adult smoking cessation advice/counseling* Blood cultures for pneumonia patients admitted through the Emergency Department.* Blood cultures for pneumonia patients in intensive care units. Pneumonia patients who are given advice about stopping smoking while they are in the hospital. This measure reports what percent of adult pneumonia patients are provided advice and/or counseling to quit smoking. Smoking harms the heart, lungs and blood vessels and makes existing disease worse. Limitations of measure use - see Accreditation Quality Report User Guide. Pneumonia patients who were admitted through the Emergency Department who had a blood test in the Emergency Department for the presence of bacteria in their blood. Before antibiotics are given, blood samples are taken to test for the type of infection. This measure reports the percent of pneumonia patients admitted through the Emergency Department who received this test before antibiotics were given. Pneumonia patients cared for in an intensive care unit that had a blood test for the presence of bacteria in their blood within 24 hours of hospital arrival. This measure reports the percent of pneumonia patients in intensive care units who had a blood culture within 24 hours prior to or after hospital arrival. Compared to other Joint Commission Measure Area Explanation Nationwide Statewide Pneumonia Care This category of evidence based measures assesses the overall quality of care provided to Pneumonia patients. of 143 eligible 93% of 318 eligible of 44 eligible Compared to other Joint Commission Nationwide Statewide Top 10% Top 10% Scored : Scored : * This information is part of the Quality Alliance. This information can also be viewed at 22 Copyright 2011, The Joint Commission

23 National Quality Improvement Goals Symbol Key This organization achieved the best possible results above the target range/value. similar to the target range/value. below the target range/value. Not displayed Footnote Key The Measure or Measure Set was not reported. The Measure Set does not have an overall result. The number of patients is not enough for comparison purposes. The measure meets the Privacy Disclosure Threshold rule. The organization scored above 90% but was below most other organizations. The Measure results are not statistically valid. The Measure results are based on a sample of patients. The number of months with Measure data is below the reporting requirement. The measure results are temporarily suppressed pending resubmission of updated data. Measure Explanation Results Initial antibiotic received within 6 hours of hospital arrival* Initial antibiotic selection for CAP in immunocompetent ICU patient* Initial antibiotic selection for CAP in immunocompetent non ICU patient* Pneumonia patients who are given an antibiotic within 6 hours of arriving at the hospital. This measure reports the percent of adult pneumonia patients who are given an antibiotic within 6 hours of arriving at the hospital. Limitations of measure use - see Accreditation Quality Report User Guide. in intensive care units who have community-acquired pneumonia who received the appropriate medicine (antibiotic) that has been shown to be effective for community-acquired pneumonia. This measure reports how often patients in intensive care units with community-acquired pneumonia were given the correct antibiotic within 24 hours of hospital arrival, based on recommendations from written guidelines, for the treatment of pneumonia. not in intensive care units who have community-acquired pneumonia who received the appropriate medicine (antibiotic) that has been shown to be effective for community-acquired pneumonia. This measure reports how often patients with community-acquired pneumonia not cared for in intensive care units, were given the correct antibiotic within 24 hours of hospital arrival, based on recommendations from written guidelines, for the treatment of pneumonia. Compared to other Joint Commission Measure Area Explanation Nationwide Statewide Pneumonia Care This category of evidence based measures assesses the overall quality of care provided to Pneumonia patients. of 332 eligible Compared to other Joint Commission Nationwide Statewide Top 10% Top 10% Scored : Scored 3 50% of 18 eligible 3 94% of 233 eligible : 72% 73% * This information is part of the Quality Alliance. This information can also be viewed at 23 Copyright 2011, The Joint Commission

24 National Quality Improvement Goals Symbol Key This organization achieved the best possible results above the target range/value. similar to the target range/value. below the target range/value. Not displayed Footnote Key The Measure or Measure Set was not reported. The Measure Set does not have an overall result. The number of patients is not enough for comparison purposes. The measure meets the Privacy Disclosure Threshold rule. The organization scored above 90% but was below most other organizations. The Measure results are not statistically valid. The Measure results are based on a sample of patients. The number of months with Measure data is below the reporting requirement. The measure results are temporarily suppressed pending resubmission of updated data. Measure Explanation Results Pneumococcal vaccination* Pneumonia vaccination. This measure reports how many patients 65 years and older were screened and vaccinated to prevent pneumonia. Compared to other Joint Commission Measure Area Explanation Nationwide Statewide Pneumonia Care This category of evidence based measures assesses the overall quality of care provided to Pneumonia patients. of 273 eligible * This information is part of the Quality Alliance. This information can also be viewed at Compared to other Joint Commission Nationwide Statewide Top 10% Top 10% Scored : Scored : 94% 24 Copyright 2011, The Joint Commission

25 National Quality Improvement Goals Symbol Key This organization achieved the best possible results above the target range/value. similar to the target range/value. below the target range/value. Not displayed Footnote Key The Measure or Measure Set was not reported. The Measure Set does not have an overall result. The number of patients is not enough for comparison purposes. The measure meets the Privacy Disclosure Threshold rule. The organization scored above 90% but was below most other organizations. The Measure results are not statistically valid. The Measure results are based on a sample of patients. The number of months with Measure data is below the reporting requirement. The measure results are temporarily suppressed pending resubmission of updated data. Measure Explanation Results Pneumonia Seasonal Measure Reporting Period: October March 2010 Influenza vaccination Pneumonia patients in the hospital during flu season (October through March) who were given the influenza vaccination prior to leaving the hospital. This measure reports how often pneumonia patients in the hospital during the flu season were given flu vaccine if needed, prior to leaving the hospital. Compared to other Joint Commission Measure Area Explanation Nationwide Statewide Pneumonia Care This category of evidence based measures assesses the overall quality of care provided to Pneumonia patients. 94% of 103 eligible * This information is part of the Quality Alliance. This information can also be viewed at Compared to other Joint Commission Nationwide Statewide Top 10% Top 10% Scored : Scored : 92% 92% 25 Copyright 2011, The Joint Commission

26 26 Copyright 2011, The Joint Commission

27 National Quality Improvement Goals - Quarterly Results Pneumonia Care Adult smoking cessation advice/counseling* Nationwide Blood cultures for pneumonia patients admitted through the Emergency Department.* % 94% 94% Nationwide Blood cultures for pneumonia patients in intensive care units % Nationwide Influenza vaccination *** *** 94% *** *** Nationwide 90% * This information is part of the Quality Alliance. This information can also be viewed at *** The measure was not in effect for this quarter. 1 - The measure or measure set was not reported. 3 - The number of patients is not enough for comparison purposes. 4 - The measure meets the Privacy Disclosure Threshold rule. 7 - The measure results are based on a sample of patients. 8 - The number of months with measure data is below the reporting requirement. 94% *** *** 27 Copyright 2011, The Joint Commission

28 National Quality Improvement Goals - Quarterly Results Pneumonia Care Initial antibiotic received within 6 hours of hospital arrival* % Nationwide Initial antibiotic selection for CAP in immunocompetent ICU patient* % 60% 67% Nationwide 70% 71% 75% 77% Initial antibiotic selection for CAP in immunocompetent non ICU patient* % Nationwide Pneumococcal vaccination* Nationwide 94% 94% * This information is part of the Quality Alliance. This information can also be viewed at *** The measure was not in effect for this quarter. 1 - The measure or measure set was not reported. 3 - The number of patients is not enough for comparison purposes. 4 - The measure meets the Privacy Disclosure Threshold rule. 7 - The measure results are based on a sample of patients. 8 - The number of months with measure data is below the reporting requirement. 28 Copyright 2011, The Joint Commission

29 National Quality Improvement Goals Symbol Key This organization achieved the best possible results above the target range/value. similar to the target range/value. below the target range/value. Not displayed Footnote Key The Measure or Measure Set was not reported. The Measure Set does not have an overall result. The number of patients is not enough for comparison purposes. The measure meets the Privacy Disclosure Threshold rule. The organization scored above 90% but was below most other organizations. The Measure results are not statistically valid. The Measure results are based on a sample of patients. The number of months with Measure data is below the reporting requirement. The measure results are temporarily suppressed pending resubmission of updated data. Measure Explanation Results Surgery patients taking a Beta-Blocker before hospital admission who received a Beta-Blocker in the time frame of 24 hours before surgery through the time they were in the recovery room. This measure reports the number of patients taking a Beta-Blocker medication before hospital admission who received a Beta-Blocker in the time frame of 24 hours before surgery through the time they were in the recovery room. Risk of complications is decreased when the Beta-Blocker is continued during the surgical time frame. Compared to other Joint Commission Measure Area Explanation Nationwide Statewide SCIP - Cardiac This evidence based measure assesses continuation of beta-blocker therapy in selected surgical patients. of 306 eligible * This information is part of the Quality Alliance. This information can also be viewed at Compared to other Joint Commission Nationwide Statewide Top 10% Top 10% Scored : Scored : 94% 29 Copyright 2011, The Joint Commission

30 National Quality Improvement Goals - Quarterly Results SCIP - Cardiac Surgery patients taking a Beta-Blocker before hospital admission who received a Beta-Blocker in the time frame of 24 hours before surgery through the time they were in the recovery room % Nationwide 93% 94% 94% * This information is part of the Quality Alliance. This information can also be viewed at *** The measure was not in effect for this quarter. 1 - The measure or measure set was not reported. 3 - The number of patients is not enough for comparison purposes. 4 - The measure meets the Privacy Disclosure Threshold rule. 7 - The measure results are based on a sample of patients. 8 - The number of months with measure data is below the reporting requirement. 30 Copyright 2011, The Joint Commission

31 National Quality Improvement Goals Symbol Key This organization achieved the best possible results above the target range/value. similar to the target range/value. below the target range/value. Not displayed Footnote Key The Measure or Measure Set was not reported. The Measure Set does not have an overall result. The number of patients is not enough for comparison purposes. The measure meets the Privacy Disclosure Threshold rule. The organization scored above 90% but was below most other organizations. The Measure results are not statistically valid. The Measure results are based on a sample of patients. The number of months with Measure data is below the reporting requirement. The measure results are temporarily suppressed pending resubmission of updated data. Measure Explanation Results having a surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.* having surgery who received the appropriate medicine (antibiotic) which is shown to be effective for the type of surgery performed.* This measure reports how often patients having surgery received medicine that prevents infection (an antibiotic) within one hour before the skin was surgically cut. Infection is lowest when patients receive antibiotics to prevent infection within one hour before the skin is surgically cut. Note: Not every surgery requires antibiotics and this measure reports on those selected surgeries where evidence/experts have identified that antibiotics would be helpful. This measure reports how often patients who had surgery were given the appropriate medicine (antibiotic) that prevents infection which is know to be effective for the type of surgery, based upon the recommendations of experts around the country. Note: Not every surgery requires antibiotics and this measure reports on those selected surgeries where evidence/experts have identified that antibiotics would be helpful. Compared to other Joint Commission Measure Area Explanation Nationwide Statewide SCIP - Infection Prevention This category of evidence based measures assesses the overall use of indicated antibiotics for surgical infection prevention. of 528 eligible of 531 eligible Compared to other Joint Commission Nationwide Statewide Top 10% Top 10% Scored : Scored : * This information is part of the Quality Alliance. This information can also be viewed at 31 Copyright 2011, The Joint Commission

32 National Quality Improvement Goals Symbol Key This organization achieved the best possible results above the target range/value. similar to the target range/value. below the target range/value. Not displayed Footnote Key The Measure or Measure Set was not reported. The Measure Set does not have an overall result. The number of patients is not enough for comparison purposes. The measure meets the Privacy Disclosure Threshold rule. The organization scored above 90% but was below most other organizations. The Measure results are not statistically valid. The Measure results are based on a sample of patients. The number of months with Measure data is below the reporting requirement. The measure results are temporarily suppressed pending resubmission of updated data. Measure Explanation Results who had surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.* Having Blood Vessel Surgery* having blood vessel surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.* having blood vessel surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.* This measure reports how often surgery patients whose medicine (an antibiotic) to prevent infection was stopped within 24 hours after the surgery ended. Giving medicine that prevents infection for more than 24 hours after the end of surgery is not helpful, unless there is a specific reason (for example, fever or other signs of infection). Note: Not every surgery requires antibiotics and this measure reports on those selected surgeries where evidence/experts have identified that antibiotics would be helpful. Overall report of hospital's performance on Surgical Infection Prevention Measure for Blood Vessel Surgery. This measure reports how often patients having blood vessel surgery received medicine that prevents infection (an antibiotic) within one hour before the skin was surgically cut. Infection is lowest when patients receive antibiotics to prevent infection within one hour before the skin is surgically cut. This measure reports how often patients who had blood vessel surgery were given the appropriate medicine (antibiotic) that prevents infection which is know to be effective for the type of surgery, based upon the recommendations of experts around the country. Compared to other Joint Commission Measure Area Explanation Nationwide Statewide SCIP - Infection Prevention This category of evidence based measures assesses the overall use of indicated antibiotics for surgical infection prevention. of 512 eligible of 69 eligible Compared to other Joint Commission Nationwide Statewide Top 10% Top 10% Scored : Scored 3 of 23 eligible 3 3 of 23 eligible 3 : * This information is part of the Quality Alliance. This information can also be viewed at 32 Copyright 2011, The Joint Commission