National Hospital Measures

The Joint Commission requires accredited hospitals to collect and submit performance data on Heart Attack, Heart Failure, Pneumonia and the Surgical Care Improvement Project. This requirement was established to improve the safety and quality of care and to support performance improvement in hospitals. PeaceHealth participates in this initiative not only to comply with the regulatory agencies, but also to demonstrate our commitment to exceptional medicine and compassionate care.

Key
~	Data not yet available or measure not applicable to this hospital
*	Too few cases. Data hidden to protect patient confidentiality.

Hospital Measure	All PeaceHealth	Sacred Heart Medical Center Riverbend	Sacred Heart Medical Center University District	PeaceHealth St. Joseph Medical Center	PeaceHealth St. John Medical Center	Peace Harbor Hospital	PeaceHealth Ketchikan Medical Center	Cottage Grove Community Hospital	National Average	National Top 10%
Pneumonia  (4/1/2011 - 6/30/2011)
Pneumococcal screening and/or vaccination	92%	85%	91%	95%	94%	100%	100%	90%	95%	100%
Blood culture for transfers to intensive care unit (ICU)	96%	100%	~	100%	89%	*	*	~	97%	100%
Blood culture in ED prior to initial antibiotic	91%	97%	89%	94%	78%	100%	94%	100%	97%	100%
Adult smoking cessation advice/counseling	94%	100%	*	95%	88%	*	100%	*	99%	100%
Antibiotic timing	2:11	2:15	2:10	2:18	1:57	1:39	2:45	1:52	2:30	~
Antibiotic received within 6 hours of arrival	97%	93%	100%	97%	100%	100%	100%	*	96%	100%
Antibiotic Selection for Community-Acquired Pneumonia	88%	95%	93%	96%	60%	100%	100%	100%	~	99%
Antibiotic selection for patients in ICU	79%	67%	~	100%	60%	*	~	~	83%	100%
Antibiotic selection for patients in non-ICU	89%	98%	93%	96%	60%	*	100%	100%	96%	100%
Influenza vaccine	~	~	~	~	~	~	~	~	94%	100%
Heart Attack  (4/1/2011 - 6/30/2011)
Aspirin at arrival	99%	100%	~	98%	100%	~	*	*	99%	100%
Aspirin prescribed at discharge	99%	100%	~	99%	100%	~	*	*	99%	100%
ACEI or ARB for LVSD	98%	95%	~	100%	*	~	*	~	97%	100%
Adult smoking cessation advice/counseling	99%	100%	~	97%	100%	~	~	~	100%	100%
Beta blocker prescribed at discharge	100%	100%	~	99%	100%	~	*	~	99%	100%
Time to fibrinolysis	~	~	~	~	~	~	~	~	0:48	~
Fibrinolytic therapy within 30 minutes of arrival	~	~	~	~	~	~	~	~	60%	100%
Time to PCI	0:54	0:45	~	1:03	~	~	~	~	1:04	~
PCI within 90 minutes of arrival	87%	94%	~	83%	~	~	~	~	92%	100%
Inpatient mortality	~	~	~	~	~	~	~	~	~	~
Heart Failure  (4/1/2011 - 6/30/2011)
Discharge instructions	89%	88%	83%	88%	93%	*	83%	100%	91%	100%
LVF assessment	98%	100%	100%	97%	98%	*	83%	100%	99%	100%
ACEI or ARB for LVSD	94%	100%	*	94%	93%	*	*	*	96%	100%
Adult smoking cessation advice/counseling	98%	100%	*	100%	90%	*	*	*	99%	100%
Surgical Care Improvement Project  (4/1/2011 - 6/30/2011)
Antibiotic received within 1 hour prior to surgery	98%	96%	~	99%	99%	100%	100%	~	98%	100%
Antibiotic selection	99%	99%	~	100%	99%	95%	100%	~	98%	100%
Antibiotic discontinued within 24 hours after surgery	97%	94%	~	98%	98%	93%	100%	~	96%	100%
Controlled post-operative blood glucose levels	94%	93%	~	95%	~	~	~	~	94%	99%
Appropriate hair removal	100%	100%	~	100%	100%	100%	100%	~	100%	100%
Beta blocker therapy	95%	93%	~	93%	100%	100%	*	~	95%	100%
Venous thromboembolism prophylaxis ordered	99%	99%	~	97%	100%	100%	*	~	96%	100%
Venous thromboembolism prophylaxis received	98%	97%	~	97%	100%	100%	*	~	94%	100%
Urinary Catheter Removed by PostOp Day 2	89%	78%	~	83%	100%	100%	*	~	92%	100%

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