Home > About Us > Mission, Vision, Values > Quality Measures

Quality Measures

quality measures little Quality Measures

Measures in green are above national benchmark.
Report on Discharge Date – starting July 2012
Hover over topics with mouse cursor for definition.

Process of Care January to March 2013 National Benchmark
Heart attack patients receive PCI within 90 minutes of arrivalDEFINITION: Acute myocardial infarction (AMI) patients with ST-segment elevation or LBBB on the ECG closest to arrival time receiving primary PCI during the hospital stay with a time from hospital arrival to percutaneous coronary intervention (PCI) of 90 minutes or less. POPULATION Adult Heart Attack patients with ST-elevation or LBBB on ECG who received primary percutaneous coronary intervention (PCI). 100% 95%
Heart failure patients receive discharge instructions specific to heart failureDEFINITION: Heart failure patients discharged home with written instructions or educational material given to patient or caregiver at discharge or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen. 94% 93%
Pneumonia patients in ED have blood cultures taken prior to receiving antibioticsDEFINITION: Pneumonia patients whose initial emergency room blood culture specimen was collected prior to first hospital dose of antibiotics. This measure focuses on the treatment provided to Emergency Department patients prior to admission orders. 98% 97%
Pneumonia patients were given the right kind of antibioticDEFINITION: Immunocompetent patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines 95% 95%
Surgical patients receive antibiotic one hour prior to surgeryDEFINITION: Surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision. Patients who received vancomycin or a fluoroquinolone for prophylactic antibiotics should have the antibiotics initiated within two hours prior to surgical incision. Due to the longer infusion time required for vancomycin or a fluoroquinolone, it is acceptable to start these antibiotics within two hours prior to incision time. 100% 98%
Surgical patients were given the right kind of antibioticDEFINITION: Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure). 100% 99%
Surgical patients had antibiotics stopped at the right time DEFINITION: Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after Anesthesia End Time. The Society of Thoracic Surgeons (STS) Practice Guideline for Antibiotic Prophylaxis in Cardiac Surgery (2006) indicates that there is no reason to extend antibiotics beyond 48 hours for cardiac surgery and very explicitly states that antibiotics should not be extended beyond 48 hours even with tubes and drains in place for cardiac surgery. 99% 97%
Heart surgery patients with blood sugar (glucose) that is kept under control after surgeryDEFINITION: Cardiac surgery patients with controlled 6 A.M. blood glucose (less than or equal to 200 mg/dL) on postoperative day one (POD 1) and postoperative day two (POD 2) with Anesthesia End Date being postoperative day zero (POD 0). 95% 96%
Surgical patients that had urinary catheter removed by postoperative day twoDEFINITION: Surgical patients with urinary catheter removed on Postoperative Day 1 or Postoperative Day 2 with day of surgery being day zero. 94% 95%
Surgical patients who received treatments to prevent blood clotsDEFINITION: Surgery patients who received appropriate Venous Thromboembolism (VTE) prophylaxis within 24 hours prior to Anesthesia Start Time to 24 hours after Anesthesia End Time. 100% 97%
Surgery patients, who take beta blockers at home, receive them appropriately before and after surgeryDEFINITION: Surgery patients on beta-blocker therapy prior to arrival who received a beta-blocker during the perioperative period. The perioperative period for the SCIP Cardiac measure is defined as the day prior to surgery through postoperative day two (POD 2) with day of surgery being day zero. 100% 97%
Infection Prevention January to March 2013 National Benchmark
Hand Hygiene ComplianceDEFINITION: The rate of compliance of observed incidences of staff members following the hand hygiene policy. 98% 50%
Ventilator-Associated Pneumonia (Rate per 1,000 device days)DEFINITION: The rate of ICU patients per 1000 device days, requiring mechanical ventilation, who experience ventilator acquired pneumonia as defined by the Centers for Disease Control and Prevention (CDC) and National Health and Safety Network (NHSN). 0.00% 1.20%
Central Line Blood Stream Infections (Rate per 1,000 device days)DEFINITION: The rate of ICU patients per 1000 device days, requiring a central line, who experience a central line-associated bloodstream infection as defined by the Centers for Disease Control and Prevention (CDC) and National Health and Safety Network (NHSN). 2.00% 1.10%
Catheter-Associated Urinary Tract Infections (Rate per 1,000 device days)DEFINITION: The rate of ICU patients per 1000 device days who develop a symptomatic urinary tract infection where the patient had an indwelling urinary catheter at the time of or within 48 hours before onset of the infection as defined by the Centers for Disease Control and Prevention (CDC) and National Health and Safety Network (NHSN). 0.00% 1.30%
Colon SurgeryDEFINITION: The percentage of patients undergoing Colon surgery, who meet the criteria for a surgical site infection as defined by the Centers for Disease Control and Prevention (CDC) and National Health and Safety Network (NHSN)
Surgical Site Infections: NNIS Risk Score 0 0.00% 3.99%
Surgical Site Infections: NNIS Risk Score 1 0.00% 5.59%
Surgical Site Infections: NNIS Risk Score 2 no data 7.09%
Surgical Site Infections: NNIS Risk Score 3 no data 9.47%
Abdominal HysterectomyDEFINITION: The percentage of patients undergoing Abdominal Hysterectomy surgery, who meet the criteria for a surgical site infection as defined by the Centers for Disease Control and Prevention (CDC) and National Health and Safety Network (NHSN)
Surgical Site Infections: NNIS Risk Score 0 0.00% 1.10%
Surgical Site Infections: NNIS Risk Score 1 0.00% 2.20%
Surgical Site Infections: NNIS Risk Score 2 no data 4.05%
Surgical Site Infections: NNIS Risk Score 3 no data 4.05%
Patient Experience January to March 2013 National Benchmark
Rate hospital 0-10DEFINITION: This question is a single-item indicator of the hospital experience: a summary judgment of the care received, which the patient carries away from the hospital. Low ratings on this question are critical indictments that should be taken seriously. Generally speaking, however, it would take a monumental calamity or a repeated series of service breakdowns to shake a patient’s confidence and overall rating. 64% 70%
Communications with NursesDEFINITION: This aspect of the HCAHPS survey asks patients about the treatment they received from the nurses at their facility. Patients are asked how often they were treated with courtesy and respect, how often the nurses listened carefully and how often they could clearly understand what the nurses explained to them during
their stay. The percent of patients who rated the top box, “always,” is reported.		 80% 78%
Response of Hospital StaffDEFINITION: This aspect of the HCAHPS survey asks the patient about the responsiveness of staff when the patient used the call button and if the patient received necessary help to the bathroom or timely help when using the bedpan. The percent of patients who rated the top box, “always,” is reported. 62% 67%
Communications with DoctorsDEFINITION: This aspect of the HCAHPS survey asks patients about the treatment received from the doctors at their facility. Patients are asked if they were treated with courtesy and respect, if the doctors listened carefully, and if they could clearly understand what the doctors explained to them during their stay. The percent of patients who rated the top box, “always,” is reported. 77% 81%
Cleanliness of Hospital EnvironmentDEFINITION: This question asks patients to assess how frequently their room and bathroom met their expectations for cleanliness. In our culture, cleanliness is an important aspect of healing environments. Cleanliness conjures feelings of freshness, purity, and safety. Perceptions of cleanliness respond to inputs from several senses—smell, touch, and sight. Failure to meet patients’ expectations for cleanliness erodes patients’ confidence in the technical quality and safety of the facility. High performance on this item requires the efforts of all staff, not just housekeeping and maintenance. 78% 73%
Quietness of Hospital EnvironmentDEFINITION: This question asks patients to recall the frequency with which the care environment around the room was quiet. Whereas noisy environments contribute to distress, calm environments contribute to healing. Sources of noise include the activities of staff, alarms, TVs and radios, equipment motors, telephones and pagers, visitors, and other patients. 51% 60%
Pain ManagementDEFINITION: This aspect of the HCAHPS survey asks patients to comment on how often the hospital staff did everything they could to help control pain and how often their pain was actually controlled. The percent of patients who rated the top box, “always,” is reported. 71% 71%
Communication about MedicinesDEFINITION: This aspect of the HCAHPS survey focuses on how often the hospital staff discussed side effects of medications and how often the staff explained the medications’ purposes, including new medications. The percent of patients who rated the top box, “always,” is reported. 56% 63%
Discharge InformationDEFINITION: This composite asks questions about how often the hospital staff helped the patient prepare to leave the hospital; e.g., was discharge information about symptoms to look for at home in writing and did the staff ask about help at home.
The percent of patients who responded “yes” is reported.		 84% 84%

  • About Us