SCORES FOR 4 TH QUARTER, RD QUARTER, 2014
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1 SCORES FOR 4 TH QUARTER, RD QUARTER, 2014 PATIENT SATISFACTION SCORES (HCAHPS): 4 STARS OUT OF 5 (ONLY 4 AREA ACUTE CARE HOSPITALS RECEIVED A 4-STAR RATING. NONE ACHIEVED 5-STARS). STRUCTURAL MEASURES: Participation in a Systematic Database for Cardiac Surgery Yes Details of Cardiac Surgery Quality Participation in a Systematic Clinical Database Registry for Stroke Care Yes Details of Stroke Care Quality ACUTE MYOCARDIAL INFARCTION (AMI) Aspirin Prescribed at Discharge 100% of 78 patients 99% Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival N/A (no cases met criteria) 60% Primary PCI Received Within 90 Minutes of Hospital Arrival 95% of 39 patients 96% Statin Prescribed at Discharge 99% of 75 patients 99% HEART FAILURE (HF) Discharge Instructions 95% of 58 patients 94% Evaluation of LVS Function 100% of 264 patients 99% ACEI or ARB for LVSD 100% of 19 patients 97% HEART FAILURE (HF) Discharge Instructions 95% of 58 patients 94% Evaluation of LVS Function 100% of 264 patients 99% ACEI or ARB for LVSD 100% of 19 patients 97% STROKE (STK) Venous Thromboembolism (VTE) Prophylaxis 98% of 217 patients 96% Discharged on Antithrombotic Therapy 100% of 200 patients 99% Anticoagulation Therapy for Atrial Fibrillation/Flutter 100% of 41 patients 96% Thrombolytic Therapy 89% of 19 patients 79% Antithrombotic Therapy by End of Hospital Day 2 100% of 185 patients 98% Discharged on Statin Medication 96% of 159 patients 96% Stroke Education 97% of 125 patients 93% Assessed for Rehabilitation 99% of 215 patients 98%
2 VENOUS THROMBOEMBOLISM (VTE) Venous Thromboembolism Prophylaxis 94% of 526 patients 91% Intensive Care Unit Venous Thromboembolism Prophylaxis 99% of 156 patients 95% Venous Thromboembolism Patients with Anticoagulation Overlap 100% of 113 patients 95% Therapy Venous Thromboembolism Patients Receiving Unfractionated 100% of 136 patients 99% Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram Venous Thromboembolism Warfarin Therapy Discharge Instructions 100% of 76 patients 87% Hospital Acquired Potentially-Preventable Venous Thromboembolism 0% of 34 patients 6% PNEUMONIA (PN) Initial Antibiotic Selection for CAP in Immunocompetent Patient 99% of 105 patients 96% SURGICAL CARE IMPROVEMENT PROJECT (SCIP) Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical 99% of 998 patients 99% Incision Prophylactic Antibiotic Selection for Surgical Patients 100% of 998 patients 99% Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery 99% of 967 patients 98% End Time Cardiac Surgery Patients with Controlled Postoperative Blood Glucose N/A (data suppressed by N/A CMS) Urinary Catheter Removed on Postoperative Day 1 (POD 1) or 100% of 492 patients 98% Postoperative Day 2 (POD 2) with Day of Surgery being Day Zero Surgery Patients with Perioperative Temperature Management 100% of 271 patients 100% Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who 100% of 474 patients 98% Received a Beta-Blocker During the Perioperative Period Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis With 24 Hours Prior to Surgery to 24 Hours After Surgery 100% of 789 patients 99%
3 EMERGENCY DEPARTMENT (ED) Median Time from ED Arrival to ED Departure for Admitted ED Patients Admit Decision Time to ED Departure Time for Admitted Patients Performance Aggregate for All Four Quarters 199 Minutes based on 641 patients 57 Minutes based on 641 patients % Low: 214 min. Med: 258 min. High: 239 min. Very High: 331 min. Average: 274 min. Low: 60 min. Med: 88 min. High: 111 min. Very High: 130 min. Average: 97 min. IMMUNIZATION (IMM) Influenza Immunization 99% of 544 patients 93% PERINATAL CARE (PC) Effective Delivery 6% of 53 patients 4% 30-DAY RISK-STANDARDIZED CONDITION-SPECIFIC MORTALITY MEASURES Performance Number of Admissions Acute Myocardial Infarction (AMI) 30-day Mortality Chronic Obstructive pulmonary Disease (COPD) 30-day Mortality Heart Failure (HF) 30-day Mortality Pneumonia (PN) 30-day Mortality Acute Ischemic Stroke (STK) 30-day Mortality Mortality % 14.2% % 7.7% % 11.6% % 11.5% % 14.8%
4 30-DAY RISK-STANDARDIZED PROCEDURE-BASED MORTALITY MEASURES Performance Number of Admissions 30-day All-Cause Mortality Following Coronary Artery Bypass Graft (CBG) Surgery 30-DAY RISK-STANDARDIZED CONDITION-SPECIFIC READMISSION MEASURES Performance Number of Acute Myocardial Infarction (AMI) 30-day Mortality Chronic Obstructive Pulmonary Disease (COPD) 30-day Readmission Heart Failure (HF) 30-day Readmission Pneumonia 30-day Readmission Stroke (STK) 30-day Readmission 30-DAY RISK-STANDARDIZED PROCEDURE-BASED READMISSION MEASURES Performance Number of 30-day All-cause Unplanned Readmission Following Coronary Artery Bypass Graft Surgery (CABG) 30-day Readmission Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) Mortality % 3.2% Readmission % 17.0% % 20.2% % 22.0% % 16.9% % 12.7% Readmission % 14.9% % 4.8%
5 30-DAY RISK-STANDARDIZED HOSPITAL-WIDE READMISSION MEASURES Performance Number of 30-day Hospital-Wide All-Cause Unplanned Readmission RISK-STANDARDIZED COMPLICATION MEASURES Performance Number of Complication Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) Readmission 1, % 15.2% Complication % 3.1% 30-DAY CONDITION-SPECIFIC PAYMENT MEASURES Payment Category Payment Associated with a 30-day AMI Episode of Care for Acute Myocardial Infarction (PAYM-30- AMI) Payment Associated with a 30-day Episode of Care for Heart Failure (PAYM-30-HF) Payment Associated with a 30-day Episode of Care for Pneumonia (PAYM-30-PN) the Average Payment Greater than the Average Payment the Average Payment Number of Admissions Payment (Lower Limit, Upper Limit of 95% Interval Estimate) Avg. Payment 180 $22,811 $21, $16,547 $15, $14,798 $14,294
6 AHRQ MEASURES PATIENT SAFETY INDICATORS Performance Number of Individual Patient Safety Indicators (PSIs) Death among surgical inpatients with serious treatable complications Latrogenic Pneumothorax, Adult Post-Operative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT) Postoperative Wound Dehiscence Accidental Puncture or Laceration Composite Patient Safety Indicators (PSIs) Complication/Patient Safety for Selected Indicators (Composite) Healthcare Associated Infection Central Line Associated Bloodstream Infection Catheter Associated Urinary Tract Ratio of Reported to Predicted Infections (SIR) PSI (Lower Limit, Upper Limit of 95% Confidence Interval) Per 1, , , , N/A Performance difference than Benchmark 1.88 difference than Benchmark Infections SSI-Colon Surgery difference than Benchmark SSI-Abdominal Hysterectomy N/A (13) N/A MRSA Bacteremia difference than Benchmark Clostridium Difficile (C. Diff) Better than the Benchmark Reported Adherence Percentage Reported Adherence Percentage Healthcare Personnel Influenza Vaccination 82% 79%
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