Transparency: About the Measures
 


Pneumonia

Pneumonia is a condition caused by a bacterial infection of the respiratory system. Although not all patients that have pneumonia are admitted to the hospital, those with more severe cases or those who have a weakened immune system may require hospitalization so that they can receive antibiotics and other treatments more quickly.
 Oxygenation Assessment
Clinical evidence shows that low oxygen in patients with pneumonia increases the risk of poor outcomes. Supplemental oxygen in these patients reduces the risk of death from pneumonia.
 Pneumococcal screening and/or vaccination
We know that people 65 or older should be given a pneumonia vaccination. Any hospitalization is an excellent opportunity to ask them if they've been vaccinated and give them the vaccination if they haven't.
 Blood Culture in ED prior to initial antibiotic
We know that when a patient with pneumonia has a blood culture (a test showing what disease organisms are present in the patient's blood) before receiving antibiotics, the physician has a much better idea how sick the patient really is and which antibiotic will be most helpful. If the antibiotics are given before the blood culture, the information the physician has to work with is not as clear and accurate.
 Blood Culture for Transfers to Intensive Care Unit (ICU)
We know that when a patient with pneumonia has a blood culture (a test showing what disease organisms are present in the patient's blood) before receiving antibiotics, the physician has a much better idea how sick the patient really is and which antibiotic will be most helpful. If the antibiotics are given before the blood culture, the information the physician has to work with is not as clear and accurate.
 Adult Smoking Cessation Advice/Counseling
We know that smoking is responsible for one out of every five deaths in the United States. Patients who receive even brief advice about quitting smoking are more likely to quit than those who receive no advice or counseling.
 Antibiotic timing
Clinical evidence shows that if a pneumonia patient is given antibiotics within the first 4 hours or 240 minutes after admission to the hospital, that patient will have a better chance of survival. Achieving a rate lower than the National rate is our goal.
 Antibiotic received within 8 hours
Clinical evidence shows that generally pneumonia patients who receive antibiotics in a timely manner have reduced mortality and shorter hospital stays. The Thoracic Society (2001) suggests 8 hours as the maximum time from arriving at the hospital before the patients receives the first dose of antibiotics.
 Antibiotic received within 4 hours
Clinical evidence shows that generally pneumonia patients who receive antibiotics in a timely manner have reduced mortality and shorter hospital stays.
 Antibiotic selection for patients in non-ICU
The North American Antibiotic Guidelines for Pneumonia are developed from the Centers for Disease Control and other Health Care Organizations. Treatment with the right antibiotic can generally be associated with improved survival.
 Antibiotic selection for patients in ICU
The North American Antibiotic Guidelines for Pneumonia are developed from the Centers for Disease Control and other Health Care Organizations. Treatment with the right antibiotic can generally be associated with improved survival.
 Influenza vaccine
Influenza vaccination is indicated for people age 50 years and older because it is highly effective in preventing influenza-related pneumonia, hospitalization, and death. Vaccine coverage in the United States is sub- optimal. Screening and vaccination of inpatients is recommended, but hospitalization is an underutilized opportunity to provide vaccination to adults.

Heart Attack

Each year, more than a million Americans have an acute myocardial infarction – a heart attack. A heart attack is an injury to the heart muscle resulting from a loss of blood supply. It usually occurs when a clot blocks the flow of blood through an artery that supplies blood to the heart itself. A heart attack can damage part of the heart, leading to congestive heart failure. However, appropriate treatment of a patient with symptoms of a heart attack can prevent or lessen damage.
 Aspirin at Arrival
Clinical evidence shows that early treatment with aspirin reduces the risk of death from AMI.
 Aspirin Prescribed at Discharge
Clinical evidence shows that long-term use of aspirin after AMI reduces the risk of non-fatal heart attacks, non-fatal strokes and death.
 ACEI or ARB for LVSD
Clinical evidence shows that the use of an ACE or an ARB after a heart attack on the front side of the heart improves long-term survival and provides greater benefit to the patient. ACE inhibitors and ARBs work by limiting the effects of a hormone that narrows blood vessels, and may thus lower blood pressure and reduce the work the heart has to perform. Since the ways in which these two kinds of drugs work are different, your doctor will decide which drug is most appropriate for you.
 Adult Smoking Cessation Advice/Counseling
Clinical evidence shows that smoking significantly increases the risk of death following a heart attack. Patients who receive even brief advice about quitting smoking are more likely to quit than those who receive no advice or counseling.
 Beta Blocker Prescribed at Discharge
Clinical evidence shows that taking beta blockers after AMI helps reduce the risk of complications and death.
 Beta Blocker at Arrival
Clinical evidence shows that taking beta blockers soon after arrival at the hospital helps reduce the risk of complications and death.
 Time to Fibrinolysis
Clinical evidence shows that AMI patients with these particular symptoms are at a high risk of death. Fibrinolysis can significantly reduce that risk if it is done in a timely manner.
 Time to PCI
Clinical evidence shows that AMI patients with these particular symptoms are at a high risk of death. PCI can significantly reduce that risk if it is done in a timely manner.
 Inpatient Mortality
Mortality of patients with AMI represents a significant outcome potentially related to quality of care and is an undesirable outcome of care. However, the percentages reported do not account for the fact that some patients are sicker or have other pre-existing conditions that make death more likely. High rates over time may warrant investigation into the quality of care provided.
 Fibrinolytic therapy within 30 minutes of arrival
Clinical evidence shows that generally providing fibrinolytic therapy within 30 minutes of hospital arrival reduces the risk of death for patients who have an AMI.
 PCI within 90 minutes of arrival
Clinical evidence shows that generally AMI patients who receive PCI have a significant reduction in death rate and in complications from the AMI. The earlier the PCI is performed, the more effective it is in improving outcomes.

Heart Failure

Congestive heart failure is a disorder in which the heart loses its ability to pump blood efficiently. Heart failure is almost always a chronic, long-term condition, although it can sometimes develop suddenly.
 Discharge Instructions
We know that patients and their families who understand and follow physician instructions have a lower risk of being hospitalized again for heart failure.
 LVF Assessment
Clinical evidence shows that if this measurement (LVF) is not performed on patients who have heart failure symptoms, they may not receive the appropriate treatment. Measurement is usually by a test called an echocardiogram.
 ACEI or ARB for LVSD
Clinical evidence shows that the use of an ACE or an ARB in patients improves long-term survival and provides greater benefit to the patient by reducing the risk of complications. ACE inhibitors and ARBs work by limiting the effects of a hormone that narrows blood vessels, and may thus lower blood pressure and reduce the work the heart has to perform. Since the ways in which these two kinds of drugs work are different, your doctor will decide which drug is most appropriate for you.
 Adult Smoking Cessation Advice/Counseling
Clinical evidence shows that patients who receive even brief advice about quitting smoking are more likely to quit than those who receive no advice or counseling. Hospitalization can be an ideal time for a patient to stop smoking, and stopping smoking may promote the patient's recovery.

Diabetes

 Glycohemoglobin lab result less than 7
We know that patients with diabetes whose blood sugars are under good control are much more likely to have reduced complications throughout the course of their disease.

Keeping that Glycohemoglobin A1c value below 7 is considered to be good glucose control and is associated with a decreased risk for the development of complications. For a more detailed explanation of diabetes:


National Patient Safety Goals

Over the past few years, hospitals and other health care providers have become more aware of the occurrence of errors in the health care delivery system. In response, they have developed safer processes to prevent the most common causes of error.
 Use at least two ways to identify a patient (neither to be the patient’s room number) before taking or giving blood or blood products, giving medications or providing any other treatments or procedures.
By using two identifiers, health care team members can prevent the wrong patient from receiving the wrong blood product or medication or from unnecessarily having his/her blood drawn.
 Staff member who receives an order, verbally or via telephone, will "read-back" the orders to verify accuracy and completeness
Medication errors are frequently hard to detect, but can occur for a number of reasons. One known cause is the inaccurate recording of verbal test results or orders. Reading back a verbal message after writing it is one way to reduce these kinds of errors.
 Create and use a list of abbreviations, acronyms and symbols that are not to be used throughout the organization.
Medication errors are frequently hard to detect, but can occur for a number of reasons. One known cause of medication errors is the use of abbreviations, acronyms, and symbols in medication orders that do not have common meaning, or can be misread by the pharmacist or person administering the medication. To reduce these errors, doctors and other health care professionals have identified the most common abbreviation-related errors and are working to eliminate them through a variety of methods.
 Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride > 0.9%) from patient care units
Failure to dilute these solutions can lead to dangerous complications or even death. The most commonly used electrolytes are potassium chloride, potassium phosphate and sodium chloride. To prevent these concentrated solutions from being used, they should be removed from patient care area(s). In patient care areas where the concentrated form is required, access to the solution should be strictly controlled.
 Standardize and limit the number of drug concentrations
Drugs that are highly concentrated have been involved in a high percentage of medication errors and/or serious life-threatening events in hospitals. Limiting their availability and standardizing the concentrations that are available reduces the potential for causing patient harm.
 Create and use a pre-operative checklist to confirm documents and equipment are available before surgery begins
By double-checking, the health care team can ensure that the right patient will receive the right procedure on the right part of the body. In many cases, the patient will not be aware that this is happening since he/she may already be sedated.
 Mark the surgical site, and involve the patient
By double-checking, the health care team can ensure that the right patient will receive the right procedure on the right part of the body. In many cases, the patient will not be aware that this is happening since he/she may already be sedated.
 Ensure free flow protection on intravenous infusion pumps
To prevent the patient from receiving too much fluid or medication, all IV pumps should include a mechanism that prevents the solution from flowing when the tubing is removed from the pump.
 Comply with the Center for Disease Control (CDC) hand hygiene guidelines
Doctors, nurses, dentists and other health care providers come into contact with lots of bacteria and viruses. Proper hand-washing is important to avoid the spread of contagious diseases and infections.
 Manage as sentinel events cases of unanticipated death or major permanent loss of function associated with health care-acquired infection
Joint Commission believes that managing these cases as sentinel events will provide additional information-not so much about the infection itself, but about managing patients at risk for infection who have acquired an infection. In this manner, the root cause analysis will contribute to reducing the risk of patient harm from health care-associated infection.
 Ensure critical test results are sent to the responsible licensed caregiver in a timely manner
Making critical test results available to the responsible licensed caregiver in a timely manner can lead to earlier treatment for the patient, which may be essential for improving his/her health.
 Identify and, at a minimum, annually review a list of look-alike, sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs
Accurate medication management is an important component in the treatment of many diseases. A wrong medication can be given to a patient by accident and result in a serious negative event for the patient. Developing procedures to prevent these kinds of errors from happening is critical for ensuring patient safety.
 During 2005, for full implementation by January 2006, develop a process for obtaining and documenting a complete list of the patient's current medications upon the patient's admission to the organization and with the involvement of the patient.
Accurate communication of medication information is important to ensure safe and effective care for the patient.
 A complete list of the patient's medication is communicated to the next provider of service when the patient is transferred to another setting, service, practitioner or level of care within or outside the organization
Accurate communication of medication information is important to ensure safe and effective care for the patient.
 Assess patient's risk for falling, including as a result of medications that the patient is taking, and take appropriate actions to decrease risks
While all falls cannot be prevented, serious falls, injuries or deaths may be averted.

Safety Culture

 Safety Culture Score
We want our patients and our employees to have a safe environment. The survey score serves as a guide that helps us to ensure that we are providing that environment. The survey also helps to increase staff awareness about the importance of safety. Increases in the safety culture score are linked to decreases in medical errors and to decreases in employee injuries and illness.

Home Health

 Percentage of patients who get better at walking or moving around
Many patients who get home health care are recovering from an injury or illness. They may need help from a person or equipment (like a cane) to walk safely. If they use a wheelchair, they may have difficulty moving around safely. Getting better at walking or moving around in your wheelchair may be a sign that you are making progress or meeting the goals of your care plan.

If you can walk with little help, you can be more independent, may feel better about yourself, and may stay more active. This can affect your health in a good way. Your ability to walk and move around yourself may help you live independently as long as possible in your own home.

Some patients will lose function in their basic daily activities even though the home health care agency provides good care.

 Percentage of patients who get better at getting in and out of bed
You need certain physical abilities (motor skills) to get in and out of bed. Your physical abilities can be developed or maintained by managing your symptoms or through physical or occupational therapy. Getting better at getting in and out of bed may be a sign that you are making progress or meeting the goals of your care plan.

Continued weakness or a new medical problem that makes it difficult for you to get in and out of bed may require changes to your care plan. For instance, you may need extra services or assistance.

Being able to get in and out of bed by yourself may be necessary before you can do many other things to care for yourself, like getting dressed or getting to the toilet. It is especially important if you don't have informal caregivers who can help you when your home health caregiver is not there or your home health care ends.

If you stop taking care of yourself, it may mean that your health has gotten worse. In addition, your health and quality of life may get worse in the future. Some patients will lose function in their basic daily activities even though the home health care agency provides good care.

 Percentage of patients who have less pain when moving around
If you have less pain, it may mean that the home health agency is doing a good job in asking about and treating your pain.
 Percentage of patients who get better at bathing
You need certain physical abilities (motor skills) to take a bath (or shower). You may need help from a person or special equipment. Your physical abilities can be developed or maintained by managing your symptoms or through physical or occupational therapy. Getting better at bathing yourself means you may need less assistance or equipment to bathe. This may be a sign that you are making progress or meeting the goals of your care plan.

Being able to bathe yourself is important so you can be more independent, stay clean, feel better about yourself, and stay healthy. It is especially important if you don't have informal caregivers who can help you when your home health caregiver is not there or your home health care ends.

If you can take a bath with little help, you may be more independent, feel better about yourself, and stay more active. This can affect your health in a good way. Your ability to bathe yourself may help you live independently as long as possible in your own home.

If you stop taking care of yourself, it may mean that your health has gotten worse. In addition, your health and quality of life may get worse in the future. Some patients will lose function in their basic daily activities even though the home health care agency provides good care.

 Percentage of patients who get better at taking their medicines correctly (by mouth)
Some patients take medicines (by mouth) to control different diseases or conditions. It is important that you take the right medicines, at the right times, and in the right amounts. Medicines include those prescribed by a doctor, and over-the-counter medicines like pain relievers, vitamins, laxatives, and antacids that don't need a prescription.

If you can take your medicines correctly with little help, you may be more independent, feel better about yourself, and stay more active. This can affect your health in a good way. Your ability to take your medicines correctly may help you live independently as long as possible in your own home.

Tell your doctor and home health care staff :

  • all the medicines you take, including over-the counter medicines.
  • if you are allergic to or have had a bad reaction (like rashes or dizziness) to any medicine in the past.

Some patients will lose function in their basic daily activities even though the home health care agency provides good care.

 Percentage of patients who had to be admitted to the hospital
Patients may need to go into the hospital while they are getting home health care. In some instances, this may not be avoidable even with good home health care. For instance, some illnesses are not curable and, over time, will make your health worse. For some patients, a readmission to the hospital may be a planned part of continuing treatment for their medical conditions.
 Percentage of patients who need urgent, unplanned medical care
Patients may need to have urgent, unplanned medical care while they are getting home health care because of a sudden downturn in their health or because of an injury. They may need to make an urgent trip to the doctor or emergency room, or a doctor may have to make an urgent house call.

In some instances, the need for unplanned urgent care may not be avoidable even with good home health care.

 Percentage of patients whose bladder control improves

If you lose control of your bladder, you can have skin irritation which can become serious. You may lose the ability or desire to perform normal daily activities. Loss of bladder control is often treatable, depending on the cause. It is important that your doctor and home health staff help you to improve your bladder control. A catheter is not the answer, except in rare cases.

Loss of bladder control may be due to:
  • diseases that affect your nerves and/or muscles
  • urinary tract or vaginal infections
  • constipation
  • the effects of certain medicines
  • an enlarged prostate
  • weak or overactive bladder muscles
  • physical or medical conditions, such as arthritis or surgery, that make it hard to get to the bathroom or toilet
  • diabetes
Your home health care staff should help you improve bladder control by:
  • teaching you exercises to strengthen the muscles that control the bladder
  • helping you to plan and get to the bathroom on time
  • teaching you about and monitoring your medicines
  • letting the doctor know about any changes to your health
Even if treatment isn’t completely successful, the home health staff should help you feel more comfortable and more able to cope. They should explain absorbent products such as:
  • panty liners and pads
  • adult briefs for moderate to heavy leakage
  • teach you good skin care
 Percentage of patients who are short of breath less often

If you have shortness of breath you breathe faster than normal and feel like you can’t get enough air. This makes you uncomfortable and anxious. Shortness of breath can make you tire easily and unable to do normal activities. It is important that your doctor and home health staff check your breathing. They should teach you ways to improve your breathing and to be as comfortable as possible.

Expectations for your home health care experience

Your doctor and home health care nurse or therapist should teach you ways to help you become more comfortable, including

  • quitting smoking and avoid smoke
  • breathing exercises
  • positioning yourself to breath easier and encourage you to relax
  • using several pillows to sleep
  • planning for rest periods between your activities
  • limiting talking, if talking causes shortness of breath
  • opening a window or use a fan to get air moving
  • using a humidifier in the winter
  • when and how to use oxygen or medicine, as your doctor ordered

Some patients who have a chronic breathing problem like emphysema may not get better even though the home health care agency provides good care. In these cases the doctor and home health agency’s job is to make the patient as comfortable as possible.

 Percentage of patients who stay at home after an episode of home health care ends

Most people would rather stay at home and take care of themselves rather than go into a nursing home or hospital. If a high percentage of a home health agency’s patients stay at home after an episode of their home health care ends, it may indicate that the home health agency has done its job of checking on their patients’ health status at each visit to find and treat problems early.

Home health staff can help you stay at home by doing things like:

  • checking to see that you are getting the treatment and medicine you need
  • monitoring what you eat and drink
  • checking to see that you are able to get around your home safely
  • letting the doctor know of any changes to your health
  • teaching the patient and family how to provide needed care after home health care ends

The home health staff should call your doctor if there are signs that your health has declined. You or your caregiver may also call your doctor if your health worsens or you think your home health services are ending too early.

 Percentage of patients whose wounds improved or healed after an operation
Normal wound healing after an operation is an important marker of good care. Patients whose wounds heal normally generally feel better and can get back to their daily activities sooner than those whose wounds don't heal normally. After an operation, patients often go home to recover and their doctor may refer them for home health care. One way to measure the quality of care that home health agencies give is to look at how well their patients' wounds heal after an operation.
 Percentage of patients who need unplanned medical care related to a wound that is new, is worse, or has become infected
Some visits to the emergency room for wound problems can be prevented with proper care and attention by the home health agency. Consumers, hospital discharge planners, and doctors believe this measure is a good marker of the quality of care given by a home health agency. In many cases, a visit by the home health nurse can prevent a visit to the emergency room/hospital. The nurse would assess the patient's general health and wound, discuss these findings with the doctor, carry out changes in orders, and schedule follow-up visits to evaluate progress. If any signs of infection or other problems are present, the nurse should call the doctor to alert him/her about the wound and ask if there are additional orders prior to sending the patient to the hospital.

Patient Satisfaction

 Overall the quality of care I received was excellent.
Information from patient satisfaction surveys helps us to determine what we are doing well and where we need to improve.
 I would not hesitate to recommend this hospital to my family and friends
Information from patient satisfaction surveys helps us to determine what we are doing well and where we need to improve.
 Overall, I am satisfied with the care I received
Information from patient satisfaction surveys helps us to determine what we are doing well and where we need to improve.

Organizational Health

 Organizational Health Survey Score
The Organizational Health Survey helps to inform and guide PeaceHealth leaders. It provides invaluable information about where to strengthen efforts to improve caregivers’ work experience, their connection to the organization, with patients and one another, and the joy and pride they feel working at PeaceHealth. We recognize that we can give our patients and their families only what we have ourselves. Therefore, to provide care that is truly healing, we believe everyone needs to be treated with compassion, caring, understanding, dignity, and love.
   
 

© Joint Commission on Accreditation of Healthcare Organizations, 2004. Reprinted with permission.
 
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