Quality

Core Measures

• Childrens Asthma
  • Received Reliever Medication while Hospitalized
  
  
  • Received Systemic Corticosteroids while Hospitalized
  
  
  • Received a Home Management Plan of Care while Hospitalized


• Heart Attack
  • ACE Inhibitor or ARB medications at
    discharge for heart attack patients
  
  
  • Aspirin at arrival
  
  
  • Aspirin prescribed at discharge
  
  
  • Beta blocker prescribed at discharge
  
  
  • PCI/angioplasty received within 90 minutes of hospital arrival
  
  
  • Advice for heart attack patients to quit smoking
  
  
  • 30-day heart attack mortality rate
  
  
  • 30-day adjusted heart attack readmission rate


• Heart Failure
  • ACE Inhibitor or ARB medications at discharge for heart failure patients
  
  
  • Assessment of left ventricular function
  
  
  • Discharge Instructions
  
  
  • Advice for heart failure patients to quit smoking
  
  
  • 30-day heart failure mortality rate
  
  
  • 30-day adjusted heart failure readmission rate


• Pneumonia
  • Pneumococcal screen / vaccination
  
  
  • Initial ABX within 6 hours
  
  
  • Advice for pneumonia patients to quit smoking
  
  
  • Most appropriate initial antibiotic
  
  
  • Blood cultures prior to first antibiotic
  
  
  • Pneumonia Patients Assessed and Given Influenza Vaccination
  
  
  • 30-day pneumonia mortality rate
  
  
  • 30-day adjusted pneumonia readmission rate


• Surgical Care
  • Antibiotic Received One Hour Prior to Surgical Incision - Inpatient
  
  
  • Antibiotic Received One Hour Prior to Surgical Incision - Outpatient
  
  
  • Antibiotic Selection for Surgical Patients - Inpatient
  
  
  • Antibiotic Selection for Surgical Patients - Outpatient
  
  
  • Antibiotics Discontinued Within 24 / 48 Hours After Surgery End
  
  
  • Cardiac Surgery Patients with controlled 6 A.M. Postoperative Serum Glucose
  
  
  • Surgery Patients with Appropriate Hair Removal
  
  
  • Timely Removal of Urinary Catheter
  
  
  • Beta Blockers Prior to Admission Who Received Beta Blockers
  
  
  • Received Appropriate VTE Prophylaxis Within 24 Hours
  
  
  • Recommended VTE Prophylaxis Ordered
  
  

Additional Measures

• CABG Surgery


• Inpatient Discharge


• Mortality


• Mortality Rate for PCI

Hospital-Acquired Infections

• Colon Surgical Site Infection Rate


• Hip Surgical Site Infection Rate


• Coronary Artery Bypass Chest Surgical Site Infection Rate


• Coronary Artery Bypass Donor Surgical Site Infection Rate


• Coronary ICU Central Line Associated Blood Stream Rate


• Cardiothoracic ICU Central Line Associated Blood Stream Rate


• Medical ICU Central Line Associated Blood Stream Rate


• Surgical ICU Central Line Associated Blood Stream Rate


• Pediatric ICU Central Line Associated Blood Stream Rate


• Neonatal ICU Central Line Associated Blood Stream Rate


• Neonatal ICU Umbilical Catheter Associated Blood Stream Rate