Publicly Reported Quality Measures
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1 Publicly Reported Quality Measures
2 Five-Star Quality Rating System As part of the initiative to add five-star quality ratings to its Compare Web sites, the Centers for Medicare & Medicaid Services (CMS) publishes HCAHPS Star Ratings to the Hospital Compare Web site. Star Ratings make it easier for consumers to use the information on the Compare Web sites and spotlight excellence in healthcare quality. Twelve HCAHPS Star Ratings will appear on Hospital Compare: one for each of the 11 publicly reported HCAHPS measures, plus an HCAHPS Summary Star Rating. CMS updates the HCAHPS Star Ratings each quarter. Source Data: Source for measures obtained from Hospital Compare, Centers for Medicare & Medicaid Services. Last updated: October, 2017 Five Star Quality Rating HRH Rating Q Overall Star Rating 4
3 Infection Prevention
4 Infection Prevention Infections can cause additional medical problems for patients, increase the time a patient spends in the hospital, and sometimes can result in serious illness. The risk of healthcareassociated infections can be reduced by following best practices for infection control. Infections (Higher Rate is Better) HRH Rating Q HRH Internal Goal Preventing Ventilator Associated Pneumonia 100% 100% Central Line Associated Bloodstream Infection 100% 100% Severe Sepsis/Septic Shock 90%
5 Preventing Ventilator Associated Pneumonia The percentage of patients on ventilators that have received all of the preventative interventions. 100% 80% 60% 40% 20% 0% Q4 16 Q1 17 Q2 17 Q3 17 HRH Performance Internal Goal
6 Central Line Associated Bloodstream Infection The percentage of patients with central lines that have received all of the preventative interventions. 100% 80% 60% 40% 20% 0% Q4 16 Q1 17 Q2 17 Q3 17 HRH Performance Internal Goal
7 Severe Sepsis/Septic Shock This measures how many patients who have severe sepsis/septic shock receive the timely effective care treatment bundle recommended by evidence based practice.
8 Infection Prevention Infections can cause additional medical problems for patients, increase the time a patient spends in the hospital, and sometimes can result in serious illness. The risk of healthcareassociated infections can be reduced by following best practices for infection control. Hand Hygiene (Higher Rate is Better) HRH Performance 2016 HRH Internal Goal Hand Hygiene: Intensive Care Unit 89% 90% Hand Hygiene: Medical-Surgical Unit 99% 90%
9 Hand Hygiene: CICU What are we measuring? Hand hygiene performance in our intensive care unit (CICU).
10 Hand Hygiene: Medical-Surgical Unit What are we measuring? Hand hygiene performance in our medical-surgical unit.
11 Heart Care
12 Heart Care The information below tells you how Hancock Regional Hospital adheres to recommended guidelines for heart attack and heart failure measures. Appropriate and Timely Treatment for Heart Attack (Higher Rate is Better) HRH Performance 2016 Top 10% Nationally Aspirin Upon Hospital Arrival 97% 100%
13 Aspirin for Heart Attack These measures show how Hancock Regional Hospital provides recommended treatments for heart attack and heart failure to provide the best results for our patients.
14 Heart Care The information below tells you how Hancock Regional Hospital adheres to recommended guidelines for heart attack and heart failure measures. Post Discharge Outcomes for Heart Attack (Lower Rate is Better) HRH Performance 2016 National Performance Heart Attack 30-Day Mortality Rate 13.8% 13.6% Heart Attack 30-Day Readmission Rate 16.3% 16.3%
15 Heart Attack Mortality Rate This measure represents the percentage of patients who passed away within 30 days of being admitted for heart attack at Hancock Regional Hospital. The cause of death may have been related to the original diagnosis or could be related to any other conditions.
16 Heart Attack Readmission Rate This measure represents the percentage of patients who were re-admitted within 30 days of being admitted for heart attack at Hancock Regional Hospital. The re-admission may have been planned as part of the patients plan of care. Unplanned re-admissions may be related to the original patient condition or due to any other condition.
17 Heart Care The information below tells you how Hancock Regional Hospital adheres to recommended guidelines for heart attack and heart failure measures. Post Discharge Outcomes for Heart Failure (Lower Rate is Better) HRH Performance Q National Performance Heart Failure 30-Day Mortality Rate 11.3% 11.9% Heart Failure 30-Day Readmission Rate 22.3% 21.6%
18 Heart Failure Mortality Rate This measure represents the percentage of patients who passed away within 30 days of being admitted for heart failure at Hancock Regional Hospital. The cause of death may have been related to the original diagnosis or could be related to any other conditions.
19 Heart Failure Readmission Rate This measure represents the percentage of patients who were re-admitted within 30 days of being admitted for heart failure at Hancock Regional Hospital. The re-admission may have been planned as part of the patients plan of care. Unplanned re-admissions may be related to the original patient condition or due to any other condition.
20 Pneumonia Care
21 Pneumonia Care The information below tells you how Hancock Regional Hospital adheres to recommended guidelines for pneumonia care measures. Post Discharge Outcomes for Pneumonia (Lower Rate is Better) HRH Performance 2016 National Performance Pneumonia 30-Day Mortality Rate 18.9% 15.9% Pneumonia 30-Day Readmission Rate 15.2% 16.9%
22 Pneumonia Mortality Rate This measure represents the percentage of patients who passed away within 30 days of being admitted for pneumonia at Hancock Regional Hospital. The cause of death may have been related to the original diagnosis or could be related to any other conditions.
23 Pneumonia Readmission Rate This measure represents the percentage of patients who were re-admitted within 30 days of being admitted pneumonia at Hancock Regional Hospital. The re-admission may have been planned as part of the patients plan of care. Unplanned re-admissions may be related to the original patient condition or due to any other condition.
Publicly Reported Quality Measures
Publicly Reported Quality Measures Five-Star Quality Rating System As part of the initiative to add five-star quality ratings to its Compare Web sites, the Centers for Medicare & Medicaid Services (CMS)
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