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  (10/1/2012 - 12/31/2012)
Pneumococcal screening and/or vaccination	~	~	~	~	~	~	~	~	~	~
Blood culture for transfers to intensive care unit (ICU)	98%	96%	~	100%	97%	*	*	~	98%	~
Blood culture in ED prior to initial antibiotic	96%	98%	95%	92%	97%	100%	100%	*	98%	100%
Adult smoking cessation advice/counseling	~	~	~	~	~	~	~	~	~	~
Antibiotic timing	~	~	~	~	~	~	~	~	~	~
Antibiotic received within 6 hours of arrival	~	~	~	~	~	~	~	~	~	~
Antibiotic Selection for Community-Acquired Pneumonia	96%	94%	90%	96%	100%	100%	*	*	~	100%
Antibiotic selection for patients in ICU	86%	67%	~	89%	100%	~	*	~	86%	~
Antibiotic selection for patients in non-ICU	98%	100%	90%	98%	100%	100%	*	*	96%	~
Influenza vaccine	~	~	~	~	~	~	~	~	~	~
Heart Attack  (10/1/2012 - 12/31/2012)
Aspirin at arrival	99%	100%	*	100%	98%	*	~	~	99%	100%
Aspirin prescribed at discharge	99%	99%	*	99%	100%	*	~	~	99%	100%
ACEI or ARB for LVSD	97%	95%	~	92%	100%	~	~	~	98%	100%
Adult smoking cessation advice/counseling	~	~	~	~	~	~	~	~	~	~
Beta blocker prescribed at discharge	100%	99%	*	100%	100%	*	~	~	99%	100%
Time to fibrinolysis	~	~	~	~	~	~	~	~	~	~
Fibrinolytic therapy within 30 minutes of arrival	~	~	~	~	~	~	~	~	69%	100%
Time to PCI	0:54	0:50	~	0:55	0:46	~	~	~	~	~
PCI within 90 minutes of arrival	93%	95%	~	89%	*	~	~	~	95%	100%
Inpatient mortality	~	~	~	~	~	~	~	~	~	~
Heart Failure  (10/1/2012 - 12/31/2012)
Discharge instructions	93%	94%	89%	85%	94%	*	*	*	94%	100%
LVF assessment	100%	100%	100%	99%	100%	*	*	*	99%	100%
ACEI or ARB for LVSD	94%	100%	*	89%	82%	~	*	*	97%	100%
Adult smoking cessation advice/counseling	~	~	~	~	~	~	~	~	~	~
Surgical Care Improvement Project  (10/1/2012 - 12/31/2012)
Antibiotic received within 1 hour prior to surgery	100%	98%	~	100%	100%	100%	100%	~	99%	100%
Antibiotic selection	99%	99%	~	100%	99%	100%	100%	~	99%	100%
Antibiotic discontinued within 24 hours after surgery	98%	95%	~	97%	100%	100%	100%	~	98%	100%
Controlled post-operative blood glucose levels	96%	89%	~	100%	~	~	~	~	97%	99%
Appropriate hair removal	100%	100%	~	100%	100%	100%	100%	~	100%	100%
Beta blocker therapy	100%	100%	~	100%	100%	100%	*	~	97%	100%
Venous thromboembolism prophylaxis ordered	100%	100%	~	99%	100%	100%	100%	~	99%	100%
Venous thromboembolism prophylaxis received	99%	98%	~	99%	100%	100%	94%	~	98%	100%
Urinary Catheter Removed by PostOp Day 2	98%	96%	~	97%	100%	*	100%	~	96%	100%

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