SOMC Quality Dashboard: Fiscal Year 2008

Indicator Goal Met Indicator Goal Not Met BM = Benchmark

Indicator	Goal	BM	Jul	Aug	Sep	Oct	Nov	Dec	Jan	Feb	Mar	Apr	May	Jun	Avg
Aspirin at Arrival for AMI	≥99%	100	100	100	100	100	100	100	100	100	100	100	100	100	100
Aspirin at Discharge for AMI	≥99%	100	100	100	100	100	100	100	100	100	100	100	100	100	100
Beta Blocker on Arrival for AMI	≥99%	100	100	100	100	100	100	100	100	100	100	100	100	100	100
Beta Blocker on Discharge for AMI	≥99%	100	100	100	100	100	100	100	100	100	100	100	100	100	100
ACE Inhibitor/ARB for LVSD for AMI	≥99%	100	100	100	100	100	100	100	100	100	100	N/A	100	100	100
Smoking Cessation Advice for AMI	≥99%	100	100	100	100	100	100	100	100	100	100	100	100	100	100
Door to Fibrinolytic ≤ 30 Minutes for AMI			N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Door to P.C.I. ≤ 90 Minutes for AMI	≥75%	75	83	78	67	100	80	83	80	71	100	75	88	100	82
Perfect Care for AMI (All 6 Measures)	≥99%	99	100	100	100	100	100	100	100	100	100	100	100	100	100
ACE Inhibitor/ARB at Discharge for CHF	≥98%	98	100	100	100	100	100	100	100	100	94	100	100	92	99
LV Function Assessment for CHF	≥99%	99	96	100	100	100	100	98	100	98	100	100	100	98	99
Smoking Cessation Advice for CHF	≥99%	100	100	100	100	100	100	100	100	100	100	100	100	100	100
Discharge Instructions for CHF	≥94%	94	100	100	94	97	100	100	100	100	100	100	100	100	99
Perfect Care for CHF (All 4 Measures)	≥96%	96	96	100	95	98	100	98	100	98	98	100	100	96	98
Blood Culture Before Antibiotic for CAP	≥95%	97	89	94	100	100	100	93	97	98	95	100	100	100	97
Antibiotic Timing <6hrs for CAP	≥91%	91	96	94	100	91	96	96	100	100	97	97	95	97	97
Pneumococcal Vaccine for Eligible Patients	≥94%	94	100	95	97	100	93	98	98	98	94	97	100	100	98
O² Assessment on Arrival for CAP	≥99%	100	100	100	100	100	100	100	100	100	100	100	100	100	100
Smoking Cessation Advice for CAP	≥99%	100	100	100	100	100	100	100	100	100	100	100	100	100	100
Perfect Care for CAP (All 5 Measures)	≥92%	92	88	90	97	91	94	94	96	97	94	95	95	97	94
Antibiotic Within 1 Hour of Surgical Incision	≥95%	95	89	90	93	95	95	95	100	98	100	100	98	90	96
Appropriate Antibiotic Selection for Surgery Patients	≥90%	99	96	76	92	95	100	95	97	98	100	100	98	100	96
Prophylactic Antibiotic Discontinued Within 24 Hours for Surgery Patients	≥76%	96	43	62	82	62	87	91	100	82	90	90	90	93	83
Surgery Patients With Appropriate Hair Removal		96	96	100	98	100	100	100	100	100	100	100	98	100	99
Colorectal Surgical Patients With Normothermia in PACU		96	100	100	100	100	100	100	100	100	89	100	100	100	99
Surgery Patients on Beta Blockers Prior to Admission Who Receive Beta Blocker During Perioperative Period		96	88	78	90	100	85	100	100	100	86	89	93	100	92
Prophylactic Antibiotic Initiated Within One hour Prior to Surgical Incision (OPT)												100	100		100
Prophylactic Antibiotic Selection for Surgical Patients (OPT)												100	100		100
Aspirin at Arrival For AMI (OPT)												100	100		100
Median Time in Minutes to ECG AMI(OPT)												4	7		6
Median Time in Minutes to Transfer to Another Facility for Acute Coronary Intervention AMI (OPT)												219	N/A		219
Aspirin at Arrival for Chest Pain (OPT)												94	100		97
Median Time in Minutes to ECG for Chest Pain (OPT)												5	6		6
Non-Risk Adjusted Medicare Mortality Rate	≤4.28		3.82	3.14	3.90	2.47	1.89	2.94	2.10	3.71	3.71	1.92			2.98
CMS Non-Risk Adjusted AMI 30 Day Mortality	≤16.4		0	14.3	0	33.3	16.7	0	0	18.2	30.0	0			12
CMS Non-Risk Adjusted HF 30 Day Mortality	≤11.1		10.0	7.9	5.3	2.8	12.5	3.0	7.3	2.6	12.8	10.8			7.7
CMS Non-Risk Adjusted PN 30 Day Mortality	≤11.9		16.7	9.1	0	4.6	13.3	11.1	10.0	7.9	11.5	4.4			8.7
CMS FY07 AMI 30 Day Risk Standardized Mortality Rate	≤RSMR											18.7			18.7
CMS FY07 HF 30 Day Risk Standardized Mortality Rate	≤RSMR											10.5			10.5
CMS FY07 PN 30 Day Risk Standardized Mortality Rate	≤RSMR											7.8			7.8

Aspirin at Arrival for AMI

Acute Myocardial Infarction (AMI) patients without contraindications who received aspirin within 24 hours before or after hospital arrival.

Why is this important?

Aspirin has an antiplatelet activity which can prevent decreased blood flow.

Aspirin at Discharge for AMI

Acute Myocardial Infarction (AMI) patients without aspirin contraindications who are prescribed aspirin at hospital discharge.

Why is this important?

Aspirin has an antiplatelet activity which can prevent decreased blood flow.

Beta Blocker on Arrival for AMI

Acute Myocardial Infarction (AMI) patients without beta blocker contraindications who received a beta blocker within 24 hours after hospital arrival.

Why is this important?

Lowers blood pressure and can reduce the size of the infarction.

Beta Blocker on Discharge for AMI

Acute Myocardial Infarction (AMI) patients without beta blocker contraindications prescribed a beta blocker at discharge.

Why is this important?

Lowers blood pressure and reduces death rates.

ACE Inhibitor/ARB for LVSD for AMI

Acute Myocardial Infarction (AMI) patients with left ventricular systolic dysfunction (LVSD) and without ACEI/ARB contraindications who are prescribed an ACEI/ARB at discharge. LVSD is defined as a left ventricular ejection fraction less than 40 percent or a narrative description of left ventricular function consistent with moderate or severe systolic dysfunction.

Why is this important?

Lowers blood pressure and reduces the heart’s workload.

Smoking Cessation Advice for AMI

Acute Myocardial Infarction (AMI) patients with a history of smoking cigarettes within the past 12 months, who are given smoking cessation advice or counseling during hospital stay.

Why is this important?

Smoking increases blood pressure, constricts heart vessels and reduces the effects of Beta Blockers.

Perfect Care for AMI Patients

Acute myocardial infraction (AMI) patients that meet all the indicators:

Aspirin on Arrival for AMI
Aspirin at Discharge for AMI
Beta Blocker on Arrival AMI
Beta Blocker at Discharge for AMI
ACEI/ARB for LVSD for AMI
Smoking Cessation Advice for AMI Patients

Why is this important?

Patients receiving perfect care will achieve the optimal outcome.

ACE Inhibitor/ARB at Discharge for CHF

CHF patients with left ventricular systolic dysfunction and without ACEI/ARB contraindications who are prescribed an ACEI/ARB at hospital discharge. LVSD is defined as a left ventricular ejection fraction less than 40 percent or a narrative description of left ventricular function consistent with moderate or severe systolic dysfunction.

Why is this important?

ACEI/ARB’s are now considered first-choice treatment and are the cornerstone of CHF drug therapy.

LV Function Assessment for CHF

CHF patients with documentation that left ventricular function (LVF) was assessed before arrival, during hospitalization, or is planned for after discharge.

Why is this important?

Results from measuring LVF determines the optimal treatment options.

Smoking Cessation Advice for CHF

CHF patients with a history of smoking cigarettes within the past 12 months, who are given smoking cessation advice or counseling during hospital stay.

Why is this important?

Smoking increases blood pressure, constricts heart vessels and is the leading preventable cause of death in the US.

Discharge Instructions for CHF

CHF patients discharged home with written instructions or educational material given at discharge or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, what to do if symptoms worsen.

Why is this important?

Following discharge instructions can alleviate symptoms, slow the diseases progression and improve everyday life.

Perfect Care for CHF Patients

CHF patients that meet all the indicators:

ACE Inhibitor/ARB at Discharge for CHF
LV Function Assessment for CHF Patients
Smoking Cessation Advice for CHF Patients
Discharge Instructions for CHF Patients

Why is this important?

Patients receiving perfect care will achieve the optimal outcome.

Blood Culture Before Antibiotic for CAP

Collection of blood culture prior to first dose of antibiotic for community acquired pneumonia (CAP) patients.

Why is this important?

Antibiotics can mask the results of a blood culture and can reduce the yield of clinically useful information.

Antibiotic Timing <6hrs for CAP

Community acquired pneumonia (CAP) patients who receive their first dose of antibiotics within 6 hours after arrival at the hospital.

Why is this important?

Clinical evidence supports that timely administration of antibiotic improves patient outcome and improves survival rates.

Pneumococcal Vaccine for Eligible Patients

Community acquired pneumonia (CAP) patients age 65 years and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated.

Why is this important?

Pneumococcal vaccine is up to 75% effective in preventing Pneumococcal bacteremia and meningitis.

O² Assessment on Arrival for CAP

Community acquired pneumonia (CAP) patients who had an assessment of oxygenation by arterial blood gas measurement or pulse oximetry on arrival to the hospital.

Why is this important?

Hypoxemia is a known risk factor for poor outcomes in pneumonia patients. O² assessment determines the need for supplemental oxygen which decreases mortality rates.

Smoking Cessation Advice for CAP

Community acquired pneumonia (CAP) patients with a history of smoking cigarettes within the past 12 months, who are given smoking cessation advice or counseling during hospital stay.

Why is this important?

Smoking has been cited as the single greatest cause of disease in the US.

Perfect Care for CAP

CAP patients that meet all the indicators:

Blood culture Done Before Antibiotics Given for CAP Patients
Initial antibiotic timing for CAP < 4 Hours
Pneumococcal Vaccine for Eligible Patients
O² Assessment on Arrival for CAP
Smoking Cessation Advice for CAP

Why is this important?

Patients receiving perfect care will achieve the optimal outcome.

Antibiotic Within 1 Hour of Surgical Incision

Number of surgical patients who received prophylactic antibiotics within 1 hour prior to surgical incision (two hours if receiving Vancomycin or a Fluoroquinolone).

Why is this important?

Antibiotics reach peak levels within about 15 minutes so the closer to the time of incision given maximizes the effect of the antibiotics and reduces the incidence of post-operative infection.

Benchmark Information

Our quality indicators are Joint Commission core measures in which participation is a requirement not only from Joint Commission but also Centers for Medicare & Medicaid Services (CMS). Joint Commission and CMS provide facilities with national and statewide benchmarks which includes mean percentages and best deciles (top 10%) on each indicator. This data is publicly reported on Joint Commission’s website and the CMS website Hospital Compare.

These indicators represent best practice guidelines for caring for patients with heart failure, pneumonia, myocardial infarction and select surgical procedures.

How else does SOMC measure Quality?

SOMC submits data to Volunteer Hospitals of America (VHA) so we can benchmark with all VHA hospitals.
We participate in the Institute for Healthcare Improvement (IHI) Protecting 5 Million Lives campaign which includes the heart failure and surgical procedure indicators.
We submit data to the National Cardiovascular Data Registry (NCDR-ACC) Action registry for all myocardial infarction patients and have benchmark reports from this registry.