Publicly Reported Quality Measures

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Publicly Reported Quality Measures

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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) 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: March, 2016 Five Star Quality Rating HRH Rating Q2 2015 Overall Star Rating 4

Infection Prevention

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 Q4 2015 HRH Internal Goal Preventing Ventilator Associated Pneumonia 100% 100% Central Line Associated Bloodstream Infection 100% 100% Sever Sepsis/Septic Shock 83.38% 90%

Preventing Ventilator Associated Pneumonia The percentage of patients on ventilators that have received all of the preventative interventions.

Central Line Associated Bloodstream Infection The percentage of patients with central lines that have received all of the preventative interventions.

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.

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 Q4 2015 HRH Internal Goal Hand Hygiene: Intensive Care Unit 96% 90% Hand Hygiene: Medical-Surgical Unit 100% 90% Hand Hygiene: Emergency Department 82% 90%

Hand Hygiene: CICU What are we measuring? Hand hygiene performance in our intensive care unit (CICU), medical-surgical units and our emergency department.

Hand Hygiene: Medical-Surgical Unit What are we measuring? Hand hygiene performance in our intensive care unit (CICU), medical-surgical units and our emergency department.

Hand Hygiene: Emergency Department What are we measuring? Hand hygiene performance in our intensive care unit (CICU), medical-surgical units and our emergency department.

Heart Care

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) Primary PCI Received Within 90 Minutes of Hospital Arrival HRH Performance Q2 2015 Top 10% Nationally 100% 100%

Primary PCI 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.

Evaluation of Left Ventricular Function These measures show how Hancock Regional Hospital provides recommended treatments for heart attack and heart failure to provide the best results for our patients.

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 Q2 2015 National Performance Heart Attack 30-Day Mortality Rate 13.6% 14.2% Heart Attack 30-Day Readmission Rate 17.1% 17.0%

Heart Attack Mortality Rate This measure represents the percentage of patients who passed away within 30 days of being admitted for heart attack, heart failure or 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.

Heart Attack Readmission Rate This measure represents the percentage of patients who were re-admitted within 30 days of being admitted for heart attack, heart failure or pneumonia at Hancock Regional Hospital. The re-admission may have been planned as part of the patients plan of care. Unplanned readmissions may be related to the original patient condition or due to any other condition.

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 Failure (Higher Rate is Better) HRH Performance Q2 2015 Top 10% Nationally Evaluation of Left Ventricular Function 100% 100%

Primary PCI 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.

Evaluation of Left Ventricular Function These measures show how Hancock Regional Hospital provides recommended treatments for heart attack and heart failure to provide the best results for our patients.

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 Q2 2015 National Performance Heart Failure 30-Day Mortality Rate 12.9% 11.6% Heart Failure 30-Day Readmission Rate 19.7% 22.0%

Heart Failure Mortality Rate This measure represents the percentage of patients who passed away within 30 days of being admitted for heart attack, heart failure or 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.

Heart Failure Readmission Rate This measure represents the percentage of patients who were re-admitted within 30 days of being admitted for heart attack, heart failure or pneumonia at Hancock Regional Hospital. The re-admission may have been planned as part of the patients plan of care. Unplanned readmissions may be related to the original patient condition or due to any other condition.

Surgical Care

Surgical Care The information below tells you how Hancock Regional Hospital adheres to recommended guidelines for for preventing infection from surgical procedures. Prevention of Surgical Infections (Higher Rate is Better) Antibiotic Received Within 1 Hour Prior to Surgical Incision Appropriate Antibiotic Selection for Surgical Patients HRH Performance Q2 2015 Top 10% Nationally 100% 100% 100% 100% Antibiotics Stopped Within 24 Hours of Surgery 100% 100%

Antibiotic Received Within 1 Hour Prior to Surgical Incision This measure represents how Hancock Regional Hospital adheres to recommended guidelines for reducing the risk of infection after surgery by providing care that is know to get the best results for our patients.

Appropriate Antibiotic Selection for Surgical Patients This measure represents how Hancock Regional Hospital adheres to recommended guidelines for reducing the risk of infection after surgery by providing care that is know to get the best results for our patients.

Antibiotic Stopped Within 24 Hours of Surgery This measure represents how Hancock Regional Hospital adheres to recommended guidelines for reducing the risk of infection after surgery by providing care that is know to get the best results for our patients.

Pneumonia Care

Pneumonia Care The information below tells you how Hancock Regional Hospital adheres to recommended guidelines for pneumonia care measures. Appropriate Treatment for Pneumonia (Higher Rate is Better) HRH Performance Q2 2015 Top 10% Nationally Appropriate Antibiotic Selection 100% 100%

Appropriate Antibiotic Selection - Pneumonia These quality measures represent how Hancock Regional Hospital adheres to recommended treatments for pneumonia care for our patients.

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 Q2 2015 National Performance Pneumonia 30-Day Mortality Rate 11.7% 11.5% Pneumonia 30-Day Readmission Rate 15.9% 16.9%

Pneumonia Mortality Rate This measure represents the percentage of patients who passed away within 30 days of being admitted for heart attack, heart failure or 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.

Pneumonia Readmission Rate This measure represents the percentage of patients who were re-admitted within 30 days of being admitted for heart attack, heart failure or pneumonia at Hancock Regional Hospital. The re-admission may have been planned as part of the patients plan of care. Unplanned readmissions may be related to the original patient condition or due to any other condition.

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