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 antibiotic96%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 Pneumonia96%94%90%96%100%100%**~100%
Antibiotic selection for patients in ICU86%67%~89%100%~*~86%~
Antibiotic selection for patients in non-ICU98%100%90%98%100%100%**96%~
Influenza vaccine~~~~~~~~~~
Heart Attack  (10/1/2012 - 12/31/2012)
Aspirin at arrival99%100%*100%98%*~~99%100%
Aspirin prescribed at discharge99%99%*99%100%*~~99%100%
ACEI or ARB for LVSD97%95%~92%100%~~~98%100%
Adult smoking cessation advice/counseling~~~~~~~~~~
Beta blocker prescribed at discharge100%99%*100%100%*~~99%100%
Time to fibrinolysis~~~~~~~~~~
Fibrinolytic therapy within 30 minutes of arrival~~~~~~~~69%100%
Time to PCI0:540:50~0:550:46~~~~~
PCI within 90 minutes of arrival93%95%~89%*~~~95%100%
Inpatient mortality~~~~~~~~~~
Heart Failure  (10/1/2012 - 12/31/2012)
Discharge instructions93%94%89%85%94%***94%100%
LVF assessment100%100%100%99%100%***99%100%
ACEI or ARB for LVSD94%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 surgery100%98%~100%100%100%100%~99%100%
Antibiotic selection99%99%~100%99%100%100%~99%100%
Antibiotic discontinued within 24 hours after surgery98%95%~97%100%100%100%~98%100%
Controlled post-operative blood glucose levels96%89%~100%~~~~97%99%
Appropriate hair removal100%100%~100%100%100%100%~100%100%
Beta blocker therapy100%100%~100%100%100%*~97%100%
Venous thromboembolism prophylaxis ordered100%100%~99%100%100%100%~99%100%
Venous thromboembolism prophylaxis received99%98%~99%100%100%94%~98%100%
Urinary Catheter Removed by PostOp Day 298%96%~97%100%*100%~96%100%

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