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 selection for patients in non-ICU
The North American Antibiotic Guidelines for treatment of community acquired pneumonia are developed by the Centers for Disease Control and other health care organizations. Treatment with the recommended antibiotic is associated with improved survival.
 Antibiotic selection for patients in ICU
The North American Antibiotic Guidelines for treatment of community acquired pneumonia are developed by the Centers for Disease Control and other health care organizations. Treatment with the recommended antibiotic is 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.
 Antibiotic Selection for Community-Acquired Pneumonia
The North American Antibiotic Guidelines for treatment of community acquired pneumonia are developed by the Centers for Disease Control and other health care organizations. Treatment with the recommended antibiotic is associated with improved survival.

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 complicationsand 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
A home blood glucose test measures the level of blood glucose only at that moment. HbA1c is a blood test used to measure how well your blood sugar was controlled over the last 2-3 months. Knowing your HbA1c is an important part of managing your diabetes by making sure your treatments and medicines are working.

The American Diabetes Association recommends an HbA1c less than 7.0%.

What is a normal result?

HbA1c of 6% or less is normal. You should work with your care team to keep your HbA1c level at or below 7%. However, you and your health care team must decide what is a "normal" HbA1c level for you.

What is an abnormal result?

An abnormal result means that your blood glucose levels have been above normal over a period of weeks to months. If your HbA1c is above 7.0%, it means that your diabetes control may not be as good as it should be.

In general, the higher your HbA1c, the higher the risk that you will develop problems such as:

  • Eye disease
  • Heart disease
  • Kidney disease
  • Nerve damage
  • Stroke

This is especially true if your HbA1c remains high for a long period of time. The closer your HbA1c is to normal, the less risk you have for these complications.

How often should it be checked?

  • Every 6 months if your HbA1c is 7% or below
  • Every 3 months if your HbA1c is over 7% or if you have Type 1 Diabetes

 Glycohemoglobin lab results greater than 9
A home blood glucose test measures the level of blood glucose only at that moment. HbA1c is a blood test used to measure how well your blood sugar was controlled over the last 2-3 months. Knowing your HbA1c is an important part of managing your diabetes by making sure your treatments and medicines are working.

The American Diabetes Association recommends an HbA1c less than 7.0%.

What is a normal result?

HbA1c of 6% or less is normal. You should work with your care team to keep your HbA1c level at or below 7%. However, you and your health care team must decide what is a "normal" HbA1c level for you.

What is an abnormal result?

An abnormal result means that your blood glucose levels have been above normal over a period of weeks to months. It may mean that your diabetes control is not as good as it should be.

Talk to your care team to determine what your HbA1c should be.

How often should it be checked?

  • Every 6 months if your HbA1c is 7% or below
  • Every 3 months if your HbA1c is over 7% or if you have Type 1 Diabetes

 Low Density Lipoprotein lab results less than 100
Diabetes is a major risk factor for developing cardiovascular disease. The LDL-C test is usually done as part of a lipid analysis, which also checks total cholesterol, HDL, and triglyceride levels. Too much LDL-C, commonly called "bad cholesterol," can lead to cardiovascular disease.

The American Diabetes Association recommends an LDL-C less than 100.0 mg/dl.

What is a normal result?

An LDL-C of 100mg/dl or less is the normal goal for someone with diabetes. You should work with your care team to identify your personal LDL-C goal and to help you take steps to achieve that goal.

What is an abnormal result?

An abnormal result means that your LDL-C is too high for someone with diabetes. Your health care team will work with you on lifestyle modifications to reduce your cholesterol intake such as weight loss, increased physical activity and adjusting your diet. If your LDL-C is still high, your doctor may prescribe a drug called a statin to help lower it.

How often should it be checked?

  • Every 3 months if your LDL-C is over 100mg/dl and you are trying lifestyle modifications.
  • Every 6 weeks if your LDL-C is over 100mg/dl and your doctor prescribed you a statin.
  • Every 12 months if your LDL-C is less than 100mg/dl.

 Blood Pressure results less than 130/80
High blood pressure (hypertension) is an important risk factor for the development and worsening of many complications of diabetes. It affects up to 60% of people with diabetes. Having a normal blood pressure is as important to managing diabetes as having good control of your blood sugar for your long-term health.

The American Diabetes Association recommends a blood pressure less than 130/80 mm/Hg.

What is a normal result?

Blood pressure readings vary, but in general your blood pressure should not go above 130/80. The first number is the "systolic pressure" or the pressure in the arteries when your heart beats and fills the arteries with blood. The second number is the "diastolic pressure" or the pressure in the arteries when your heart rests between beats, filling itself with blood for the next contraction.

What is an abnormal result?

If your systolic pressure or your diastolic pressure is above 130/80, your blood pressure maybe too high. Your care team will work with you on lifestyle modifications to reduce your blood pressure such as weight loss, increased physical activity and adjusting your diet. If your blood pressure is still high, your doctor may prescribe a drug to help lower it.

How often should it be checked?

  • Every time you have an appointment with your health care team.
  • At home if recommended by your health care team.


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.
 Prior to any specimen collection, medication administration, transfusion, or treatment, the hospital actively involves the patient, or the patient's family, to identify the patient using two unique identifiers.
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.
 Before starting a blood or blood product transfusion, the patient is matched to the blood or blood product using a two person verification process that uses at least two unique patient identifiers.
 Any staff who receives a verbal order or test result writes down the information and reads back the information and the person giving the order or test result confirms the information that was read back.
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.
 A list of "do not use" abbreviations, aconyms, symbols and dose desciptions is created and applied to all handwritten or free text orders or medication documents and to preprinted forms.
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.
 Measure and evaluate (and if needed, improve) the timeliness of reporting and receipt of critical tests and critical results and values.
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.
 Implement a standardized approach to "hand off" communications, including an opportunity to ask and respond to questions.
 Identify and review at least yearly a list of look-alike, sound-alike drugs used in the hospital 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.
 Correctly label all medications and solutions, including containers (syringes, medicine cups, basins, etc.), on and off the sterile field.
 Implement a defined anticoagulant management program to individualize the care provided to each patient receiving anticoagulation therapy.
 Comply with the Centers 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 all identified cases of unanticipated death or major permanent loss of function associated with health care associated infection as sentinel events.
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.
 Implement evidence-based practices to prevent health care associated infections due to multiple drug-resistant organisms.
 Develop and test practices to prevent blood stream infections associated with venous catheters that will be fully implemented by January 1, 2010.
 Develop and test practices for preventing surgical site infections that will be fully implemented by January 1, 2010
 At the time of arrival or admission, a complete list of the patient's home medications is documented and compared to medications ordered at the start of the patient's stay and discrepancies are reconciled and documented.
Accurate communication of medication information is important to ensure safe and effective care for the patient.
 A complete and reconciled list of the patient's medication is communicated to the next provider of service when the patient is transferred to another setting, service, practioner or level of care within or outside of the hospital.
Accurate communication of medication information is important to ensure safe and effective care for the patient.
 When a patient leaves the hospital's care, a complete and reconciled list of the patient's medications is provided directly to the patient and the patient's family as needed, and the list is explained to the patient and/or family.
 In settings where medications are minimally used, or prescribed for a short duration, a modified medication reconciliation process is performed.
 Implement a patient fall reduction program that includes an evaluation of the effectiveness of the program.
While all falls cannot be prevented, serious falls, injuries or deaths may be averted.
 Patients and families are educated on the how to report concerns related to care, treatment, services and patient safety issues.
 The organization has a written plan for the prediction, prevention, and early treatment of pressure ulcers.
 Identify patients at risk for suicide
 Select a suitable method that enables health care staff to directly request additional assistance from a specially trained individual(s)when the patient(s) condition appears to be worsening.

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 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.

Patient Satisfaction

 How often did nurses communicate well with patients?
Research shows that good communication between patients and their nurse(s) is an important element for patients in evaluating hospital quality - and their hospital experience. Studies show that good communication with caregivers is related to positive healthcare outcomes, as well.
 How often did doctors communicate well with patients?
Research shows that good communication between patients and their doctor(s) is an important element for patients in evaluating hospital quality - and their hospital experience. Studies show that good communication with caregivers is related to positive healthcare outcomes, as well.
 How often did patients receive help quickly from hospital staff?
Research shows that their ability to get help when it is needed is an important element for patients in evaluating hospital quality - and their hospital experience.
 How often was patients' pain well controlled?
Research shows that the extent to which pain is controlled - as well as attentiveness of hospital staff in helping to manage their pain is an important element for patients in evaluating hospital quality and their hospital experience.
 How often did staff explain about medicines before giving them to patients?
Research shows that staff explanations about medications are an important element for patients in evaluating hospital quality - and their hospital experience.
 How often were the patients' rooms and bathrooms kept clean?
Research shows that the cleanliness of the patient room and bathroom is an important element for patients in evaluating hospital quality - and their hospital experience.
 How often was the area around patients' rooms kept quiet at night?
Research shows that the noise level around the hospital room is an important element for patients in evaluating hospital quality - and their hospital experience.
 Were patients given information about what to do during their recovery at home?
Research shows that information - specifically about what to do during their recovery at home - is an important element for patients in evaluating hospital quality and their hospital experience. Studies demonstrate that the discussion and provision of discharge instructions can improve patient health outcomes, as well.
 How do patients rate the hospital overall?
Patient "overall" ratings provide an important measure of hospital quality. Hospitals rely on patient ratings - and other survey feedback - to understand patient perspectives of their recent hospital care experience. This feedback helps hospitals identify areas needing improvement, as well as areas where the hospital is performing well.
 Would patients recommend the hospital to friends and family?
Patients' willingness to recommend a hospital is an important indicator of hospital quality. Hospitals rely on this measure to better understand patient perspectives of their recent hospital care experience. Willingness to recommend - combined with other survey feedback - helps hospitals identify areas needing improvement, as well as areas where the hospital is performing well.

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.

Surgical Care Improvement Project

 Antibiotic bundle
 Beta blocker therapy
For those patients on beta-blocker therapy, continuous beta-blocker therapy during the perioperative period has been shown to help reduce the occurrence of cardiac complications after surgery.
 Antibiotic received within 1 hour prior to surgery
Studies have shown that the lowest incidence of post-operative infection is associated with antibiotic administration during the hour prior to surgery.
 Antibiotic selection
The goal of preventing infection with antibiotics is to select a medication that is safe, cost-effective and has the ability to affect most of the likely intraoperative contaminants for the operation.
 Antibiotic discontinued within 24 hours after surgery
Surgical guidelines indicate that there is no reason to extend antibiotics beyond 24 hours after the surgery end time if there is no evidence of infection.
 Controlled post-operative blood glucose levels
High blood sugar can increase the risk of infection for surgical patients, especially patients undergoing coronary artery bypass graft (CABG).
 Appropriate hair removal
Studies show shaving causes multiple skin abrasions that may become infected after surgery. When hair removal is needed, hospitals should be using a safer method of hair removal, such as clippers or depilatory.
 Immediate postoperative normothermia
A body temperature outside the normal range poses several health risks for patients undergoing surgery, including impaired wound healing, altered drug metabolism and adverse cardiac events.
 Venous thromboembolism prophylaxis ordered
Venous thromboembolism (VTE) is one of the most common postoperative complications. Taking measures to prevent VTE is the most effective strategy for reducing the occurrence of this surgical complication.
 Venous thromboembolism prophylaxis received
Venous thromboembolism (VTE) is one of the most common postoperative complications. Taking measures to prevent VTE is the most effective strategy for reducing the occurrence of this surgical complication.
 Urinary Catheter Removed by PostOp Day 2

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

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