Quality Report
Measure: Heart Attack Care
| Quality of Care Indicator | Hospital Score3rd Q 2012 | National Average | State Average | Top 10% in the Nation |
|---|
| Aspirin at Discharge |
100% |
99% |
99% |
100% |
| PCI Within 90 minutes of Arrival |
100% |
94% |
93% |
100% |
| Statin at Discharge |
99% |
98% |
99% |
100% |
Time Period: 7/1/2012 to 9/30/2012
Measure: Heart Failure Care
| Quality of Care Indicator | Hospital Score3rd Q 2012 | National Average | State Average | Top 10% in the Nation |
|---|
| ACE Inhibitor or ARB for Left Ventricular Systolic Dysfuction (LVSD) |
96% |
96% |
96% |
100% |
| Discharge Instructions |
89% |
93% |
94% |
100% |
| Evaluation of Left Ventricular Systolic Function (LVF) |
100% |
99% |
98% |
100% |
Time Period: 7/1/2012 to 9/30/2012
Measure: Pneumonia Care
| Quality of Care Indicator | Hospital Score 3rd Q 2012 | National Average | State Average | Top 10% in the Nation |
|---|
| Appropriate Initial Antibiotic Selection |
100% |
95% |
95% |
100% |
| Blood Cultures performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital |
94% |
97% |
97% |
100% |
Time Period: 7/1/2012 to 9/30/2012
Measure: SCIP
| Quality of Care Indicator | Hospital Score 3rd Q 2012 | National Average | State Average | Top 10% in the Nation |
|---|
| Prophylactic Antibiotic within 1 hour |
100% |
98% |
98% |
100% |
| Prophylactic Antibiotic Selection |
98% |
98% |
98% |
100% |
| Antibiotic d/c within 24 hours |
99% |
97% |
97% |
100% |
| Cardiac Surgery patients with controlled 6 a.m. postoperative serum Glucose |
100% |
96% |
96% |
99% |
| Appropriate Hair Removal |
100% |
100% |
100% |
100% |
| Doctors Ordered Treatment to Prevent Blood Clots |
97% |
97% |
97% |
100% |
| Received Treatment to Prevent Blood Clots in 24 hours |
95% |
95% |
96% |
100% |
| Removal of Urinary Catheter on POD 1 or 2 |
98% |
95% |
93% |
100% |
| Beta Blocker Received Perioperatively |
97% |
96% |
96% |
100% |
| Perioperative Temperature Management |
100% |
100% |
100% |
100% |
Time Period: 7/1/2012 to 9/30/2012
Measure: Children's Asthma Care
| Quality of Care Indicator | Hospital Score 3rd Q 2012 | National Average | State Average | Top 10% in the Nation |
|---|
| Relievers for Inpatient Asthma |
100% |
100% |
NA |
NA |
| Systemic Corticosteroids for Inpatient Asthma |
100% |
100% |
NA |
NA |
| Home Management Plan |
80% |
85% |
NA |
NA |
Time Period: 7/1/2012 to 9/30/2012
Measure: Outpatient SCIP
| Quality of Care Indicator | Hospital Score 3rd Q 2012 | National Average | State Average | Top 10% in the Nation |
|---|
| Prophylactic Antibiotic within 1 hours |
99% |
80% |
97% |
100% |
| Prophylactic Antibiotic Selection |
100% |
82% |
96% |
100% |
Time Period: 7/1/2012 to 9/30/2012
Measure: Immunization
| Quality of Care Indicator | Hospital Score 3rd Q 2012 | National Average | State Average | Top 10% in the Nation |
|---|
| Pneumonia Immunization |
94% |
88% |
84% |
98% |
| Influenza Immunization |
NA |
86% |
83% |
98% |
Time Period: 7/1/2012 to 9/30/2012
Measure: Inpatient ED
| Quality of Care Indicator | Hospital Score 3rd Q 2012 | National Average | State Average | Top 10% in the Nation |
|---|
| Median Time from ED Arrival to ED Departure for Admitted ED Patients (Min) |
283 |
277 |
223 |
175 |
| Admit Decision Time to ED Departure Time for Admitted Patients (Min) |
119 |
98 |
70 |
43 |
Time Period: 7/1/2012 to 9/30/2012
Measure: Outpatient ED
| Quality of Care Indicator | Hospital Score 3rd Q 2012 | National Average | State Average | Top 10% in the Nation |
|---|
| Median Time to Pain Management for Long Bone Fracture (Min) |
78 |
58 |
70 |
26 |
| Arrival to Departure Time (min) |
172 |
59 |
129 |
20 |
| Door to Diagnostic Evaluation (min) |
45 |
59 |
31 |
29 |
| Head CT/MRI Scan Results with in 45 Minutes for Stroke Patients |
NA |
38 |
43 |
100 |
Time Period: 7/1/2012 to 9/30/2012
Safety Report
30-Day Risk Adjusted Mortality Rates
| Measure | Hospital | Predicted Range |
| Number Patients | Mortality Rate | from | to |
| Heart Attack |
427 |
18.1% |
15.1% |
21.5% |
| Heart Failure |
579 |
14.8% |
12.4% |
17.5% |
| Pneumonia |
643 |
14.9% |
12.8% |
17.4% |
30-Day Risk Adjusted Readmission Rates
| Measure | Hospital | Predicted Range | National Average |
| Number Patients | Readmission Rate | from | to |
| Heart Attack |
436 |
19.1% |
16.2% |
22.3% |
19.8% |
| Heart Failure |
753 |
23.1% |
20.6% |
26.0% |
24.8% |
| Pneumonia |
678 |
17.8% |
15.4% |
20.4% |
18.4% |
Data Source: CMS Hospital Compare July 2007 - June 2010
Satisfaction Report
| Satisfaction Indicator | Hospital Score 3rdQ 2012 | National Average | State Average | Top 10% in the Nation |
|---|
| Percent who said Nurses "Always" communicated well |
80% |
78% |
78% |
NA |
| Doctors "Always" communicated well |
82% |
81% |
83% |
NA |
| "Always" received help as soon as they wanted |
61% |
66% |
67% |
NA |
| Pain was "Always" well controlled |
72% |
70% |
71% |
NA |
| Staff "Always" explained about medicines before giving it to them |
67% |
63% |
63% |
NA |
| Room and bathroom were "Always" clean |
73% |
73% |
72% |
NA |
| Area around their room was "Always" quiet at night |
68% |
60% |
66% |
NA |
| "Always" given information about what to do at home |
81% |
84% |
81% |
NA |
| Rated hospital a 9 or 10 on a scale from 0 (lowest) to 10 (highest) |
71% |
69% |
69% |
NA |
| "Always" would definitely recommend the hospital |
73% |
70% |
69% |
NA |
Time Period: 7/1/2012 to 9/30/2012
Cost Report
| | Average Hospital Charge |
| Description (MS-DRG) | St. Bernards | NEA Baptist | Baptist LR | Baptist NLR | Ark Methodist | Washington Regional | St. Joseph's Mercy |
| Brain/Neurological |
|
|
|
|
|
|
|
| Degenerative nervous disorders without complications (057) |
$10,914 |
$18,297 |
$20,555 |
$9,452 |
$4,335 |
$15,419 |
$32,576 |
| Stroke with complications (065) |
$11,444 |
$20,561 |
$26,567 |
$16,950 |
$8,419 |
$17,666 |
$22,332 |
| Stroke without complications (066) |
$9,951 |
$13,240 |
$17,729 |
$14,099 |
$6,495 |
$12,228 |
$17,892 |
| Childbirth |
|
|
|
|
|
|
|
| C-Section with complications (765) |
$6,908 |
$11,925 |
$20,761 |
$14,735 |
$7,192 |
$13,079 |
$24,728 |
| C-Section without complications (766) |
$5,319 |
$11,449 |
$14,736 |
$13,270 |
$6,193 |
$11,245 |
$17,229 |
| Normal delivery with complications (774) |
$4,191 |
$8,584 |
$12,856 |
$9,985 |
|
$6,186 |
$14,466 |
| Normal delivery without complications (775) |
$3,460 |
$7,708 |
$9,474 |
$8,280 |
$5,347 |
$4,521 |
$11,000 |
| General Medicine |
|
|
|
|
|
|
|
| Fainting (312) |
$7,421 |
$12,651 |
$17,020 |
$10,878 |
$6,188 |
$10,002 |
$13,783 |
| Stomach disorder without complications (392) |
$5,605 |
$15,882 |
$14,225 |
$11,427 |
$5,655 |
$9,109 |
$15,319 |
| Infection of the skin (603) |
$5,458 |
$13,867 |
$11,999 |
$9,901 |
$7,845 |
$10,907 |
$13,847 |
| Diabetes without complications (639) |
$5,254 |
$14,153 |
$11,434 |
$11,982 |
$5,295 |
$10,479 |
$12,214 |
| Nutritional or metabolic disorders without complications (641) |
$4,470 |
$11,610 |
$13,889 |
$10,230 |
$4,565 |
$6,853 |
$13,655 |
| Anemia or other red blood cell disorder without complication (812) |
$7,927 |
$16,591 |
$13,429 |
$11,738 |
$5,791 |
$9,257 |
$15,382 |
| Blood infection with major compication (871) |
$17,393 |
$37,729 |
$36,861 |
$24,449 |
$16,578 |
$29,828 |
$37,301 |
| Blood infection without major complication (872) |
$11,226 |
$23,773 |
$17,530 |
$16,330 |
$11,436 |
$18,244 |
$22,931 |
| Alcohol or Drug Abuse without rehab or major complications (897) |
$3,173 |
$14,244 |
$7,550 |
$10,177 |
|
$10,626 |
$12,838 |
| Drug Overdose without complications (918) |
$6,507 |
$8,304 |
$10,556 |
$7,735 |
$4,119 |
$6,744 |
$10,094 |
| Heart / Cardiology |
|
|
|
|
|
|
|
| Drug Coated Stent in Heart Artery without complications (247) |
$21,030 |
$36,481 |
$37,764 |
$39,577 |
$34,821 |
$32,927 |
$44,854 |
| Cardiovascular Procedure without Drug Coated Stent and without complication (249) |
$19,056 |
$36,158 |
$35,081 |
$33,091 |
|
$27,977 |
$35,782 |
| Cardiac Cath without Complex Heart Diagnosis and without complications (287) |
$10,721 |
$22,202 |
$20,473 |
$17,395 |
$13,055 |
$21,429 |
$20,574 |
| Heart Failure with major complications (291) |
$12,232 |
$31,885 |
$28,996 |
$22,039 |
$14,007 |
$20,921 |
$26,451 |
| Heart failure with complications (292( |
$8,458 |
$13,784 |
$19,249 |
$15,589 |
$9,292 |
$13,214 |
$19,590 |
| Heart failure without complications (293) |
$6,917 |
$10,087 |
$12,384 |
$10,932 |
$6,579 |
$9,607 |
$15,971 |
| Abnormal or irregular heartbeat (310) |
$5,562 |
$8,151 |
$9,059 |
$9,124 |
$5,984 |
$9,053 |
$11,814 |
| Chest pain (313) |
$6,671 |
$8,433 |
$11,204 |
$10,307 |
$6,081 |
$9,014 |
$12,129 |
| Kidney/Urology |
|
|
|
|
|
|
|
| Kidney/urinary infection without complications (690) |
$6,085 |
$20,213 |
$12,502 |
$10,005 |
$5,894 |
$9,105 |
$14,677 |
| Lung/Pulmonary |
|
|
|
|
|
|
|
| Respiratory Failure (189) |
$12,977 |
$17,331 |
$27,375 |
$17,837 |
$18,049 |
$22,922 |
$27,965 |
| Chronic Lung Disease with complications (191) |
$8,678 |
$16,160 |
$18,300 |
$14,779 |
$9,177 |
$15,743 |
$16,522 |
| Chronic Lung Disease without complications (192) |
$7,941 |
$13,985 |
$13,536 |
$10,378 |
$7,537 |
$11,005 |
$14,479 |
| Pneumonia with complications (194) |
$9,036 |
$18,980 |
$17,140 |
$12,179 |
$10,069 |
$12,787 |
$18,290 |
| Pneumonia without complications (195) |
$6,381 |
$12,827 |
$9,617 |
$9,881 |
$7,154 |
$7,661 |
$12,854 |
| Bronchitis or asthma without complications (203) |
$4,341 |
$11,316 |
$7,244 |
$7,002 |
$4,678 |
$6,457 |
$8,920 |
| Newborns |
|
|
|
|
|
|
|
| Newborn with significant problems (794) |
$1,395 |
$1,489 |
$4,681 |
$2,288 |
$1,155 |
$3,588 |
$3,741 |
| Normal newborn (795) |
$952 |
$1,113 |
$2,471 |
$1,756 |
$778 |
$1,730 |
$1,928 |
| Orthopedic Surgery |
|
|
|
|
|
|
|
| Shoulder or hip replacement without major complications (470) |
$17,230 |
$32,218 |
$32,736 |
$29,841 |
$24,713 |
$34,763 |
$41,846 |
| Surgery |
|
|
|
|
|
|
|
| Uterus or Ovary Surgery not related to cancer without complications (743) |
$5,992 |
$14,697 |
$15,197 |
$13,476 |
$7,134 |
$17,098 |
$16,976 |
Data Source: MedPAR data 2007
