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National
Quality Improvement Goals
Heart
attack, heart failure and pneumonia are three
conditions that most commonly bring patients into a hospital for
medical treatment. The Joint Commission on the Accreditation of
Healthcare Organizations (TJC) has established treatment
guidelines that when followed have been shown to help patients
recover more quickly with fewer complications or lasting
effects.
These
guidelines cover:
Lee Memorial Health
System's performance compared to other hospitals around the
nation and the state are highlighted below. These data reflect
care given to patients treated from July 2008 through
June 2009.
Heart Attack Care
PERFORMANCE RESULTS
For a more detailed
explanation of each of the Heart Attack Care Quality Measures
listed below, visit
hospitalcompare.hhs.gov, or
qualitycheck.org web sites.
|
Heart Attack Care Quality Measures
|
|
Time Period: July 2008
through June 2009 |
|
Quality Measure |
Lee Memorial Health System
|
Florida Hospital Average |
National Average* |
|
Aspirin at Arrival
Heart attack
patients who
received aspirin within
24 hours before or after they arrived at
the hospital.
Higher percentages are
better. |
96% |
98% |
98% |
|
Aspirin at Discharge
Heart attack patients
who receive a
prescription for aspirin when discharged
from the hospital.
Higher percentages are
better. |
94% |
98% |
98% |
|
Angiotensin Converting Enzyme (ACE)
Inhibitor or
Angiotensin Receptor Blocker (ARB)
for Left Ventricular Systolic
Dysfunction (LVSD)
Heart attack patients who receive either
a prescription for an “ACE inhibitor” or
an angiotensin receptor blocker (ARB)
when they are discharged from the
hospital.
Higher percentages are
better. |
82% |
95% |
95% |
|
Beta Blocker on Discharge
Heart attack patients who
receive a medicine called
a "beta blocker" when they are
discharged from the hospital.
Higher percentages are
better. |
98% |
98% |
98% |
|
Percutaneous Coronary Intervention
Therapy
Heart attack patient
with a clogged artery in
the heart that is opened with a balloon
angioplasty (called PCI) within 90
minutes of hospital arrival.
Higher percentages are
better. |
73% |
85% |
85% |
|
Advice on Quitting Smoking
Heart attack patients
with a history of
smoking cigarettes,
who were
given advice about
stopping smoking while in the hospital.
Higher percentages are
better. |
100% |
100% |
99% |
|
|
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Heart Failure Care
PERFORMANCE RESULTS
For a more detailed explanation
of each of the Heart Failure Care Quality Measures listed below,
visit
hospitalcompare.hhs.gov or
qualitycheck.org web sites.
|
Heart Failure Care Quality Measures
|
|
Time Period: July 2008
through June 2009 |
|
Quality Measure |
Lee Memorial Health System
|
Florida Hospital Average |
National Average* |
|
Assessment of Left Ventricular Function
Heart
failure patients
with documentation
in the hospital record that left
ventricular function (LVF) was assessed
before arrival, during hospitalization,
or is planned for after discharge.
Higher percentages are
better. |
97% |
98% |
98% |
|
Angiotensin Converting Enzyme (ACE)
Inhibitor or
Angiotensin Receptor Blocker (ARB)
for Left Ventricular Systolic Dysfunction (LVSD)
Heart failure patients
with left ventricular systolic
dysfunction (LVSD) and without
angiotensin converting enzyme inhibitor
(ACE inhibitor) contraindications or
angiotensin receptor blocker (ARB)
contraindications who are prescribed an
ACE inhibitor or an ARB at hospital
discharge.
Higher percents are
better.
|
84% |
95% |
94% |
|
Discharge Instructions
Heart failure patients
discharged home
with written instructions or educational
material given to patient or caregiver
at discharge or during the hospital stay
addressing all of the following:
activity level, diet, discharge
medications, follow-up appointment,
weight monitoring, and what to do if
symptoms worsen.
Higher percentages are
better. |
59% |
88% |
86% |
|
Advice on Quitting Smoking
Heart failure patients
with a history of
smoking cigarettes, who are given
smoking cessation advice or counseling
during a hospital stay.
Higher percentages are
better. |
96% |
99% |
98% |
*These data represent all
hospitals across the United States that report
data to the Joint Commission for the
Accreditation of Healthcare Organizations (TJC).
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Pneumonia Care PERFORMANCE
RESULTS
For a more detailed explanation of each of
the Pneumonia Care Quality Measures listed
below, visit the
hospitalcompare.hhs.gov
or
qualitycheck.org
websites.
|
Pneumonia Care Quality Measures
|
|
Time Period: July 2008
through June 2009 |
|
Quality Measure |
Lee Memorial Health System
|
Florida Hospital Average |
National Average* |
|
Initial Antibiotic Timing
within 6 Hours of
Arrival
Pneumonia inpatients that receive an
antibiotic within six hours of arriving at the hospital.
Higher percentages are
better. |
89% |
95% |
94% |
|
Pneumococcal Vaccination
Pneumonia inpatients age 65 and older
who were screened for pneumococcal
vaccine status and were administered the
vaccine prior to discharge, if
indicated.
Higher percentages are
better. |
91% |
94% |
91% |
|
Blood Cultures for
Pneumonia Patients admitted through the
Emergency Department
Pneumonia patients admitted through the
Emergency Department whose initial
hospital blood culture specimen was
collected prior to first hospital dose
of antibiotics.
Higher percentages are
better. |
94% |
95% |
94% |
|
Blood Cultures for
Pneumonia Patients in Intensive Care
Units
Pneumonia patients cared for in
Intensive Care Units whose initial
hospital blood culture specimen was
collected within 24 hours of hospital
arrival.
Higher percentages are
better. |
96% |
96% |
95% |
|
Advice on Quitting Smoking
Pneumonia patients
with a history of
smoking cigarettes,
who were
given advice about
stopping smoking while in the hospital.
Higher percentages are
better. |
95% |
99% |
97% |
Influenza
Vaccination**
Percent of
pneumonia patients during flu season
(December through February) who were
given the influenza vaccination before
leaving the hospital.
Higher percentages are
better. |
84% |
92% |
89% |
|
**Pneumonia Seasonal Measure - Reporting
Period:
October 2008 - March 2009 |
Initial Antibiotic Selection for
Community-Acquired Pneumonia (CAP) in
ICU Patients
Percent of intensive care patients who have
community-acquired pneumonia and
received the appropriate antibiotic
within 24 hours of arriving at the
hospital.
Higher percentages are
better. |
59% |
70% |
64% |
Initial Antibiotic Selection for Community-Acquired
Pneumonia (CAP) in
Non-ICU Patients
Percent of patients not in intensive care units who
have community-acquired pneumonia and
received the appropriate antibiotic
within 24 hours of arriving at the
hospital.
Higher percentages are
better. |
88% |
95% |
94% |
* These data represent
all hospitals across the United States that
report data to the Joint Commission for the
Accreditation of Healthcare Organizations (TJC).
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Surgical Infection Prevention
PERFORMANCE RESULTS
For a more detailed explanation of each of
the Surgical Infection Prevention Process of
Care Quality Measures listed
below, visit the
hospitalcompare.hhs.gov
or
qualitycheck.org
websites.
|
Surgical Care Infection
Prevention Quality Measures
|
|
Time Period: July 2008
through June 2009 |
|
Quality Measure |
Lee Memorial Health
System
|
Florida Hospital Average |
National Average* |
|
Preventative
Antibiotic(s) Received One Hour Before
Surgery
Percent of patients having a surgery who
received medicine to prevent infection
(an antibiotic) within one hour before
the skin was surgically cut.
Higher percentages are
better. |
91% |
96% |
95% |
|
Selection of
Appropriate Preventative Antibiotic(s)
Percent of
patients having surgery who received the
appropriate medicine (antibiotic) which
is shown to be effective for the type of
surgery performed.
Higher percentages are
better. |
93% |
97% |
97% |
|
Preventative
Antibiotic(s) Discontinued 24 Hours
After Surgery Percent of patients who had surgery who
received medicine that
prevents infection (antibiotic) and the
antibiotic was stopped within 24 hours
after the surgery ended.
Higher percentages are
better. |
88% |
93% |
92% |
Patients with
Recommended Venous Thromboembolism (VTE)
Prophylaxis Ordered
Percent of patients having surgery who
received medicine to prevent blood
clots.
Higher percentages are
better. |
83% |
93% |
93% |
|
Patients with
Recommended Venous Thromboembolism (VTE)
Prophylaxis Ordered for the Type of
Surgery Performed Percent
of patients who had surgery and received
appropriate medicine that prevents blood
clots for the surgery performed.
Treatment may be medication,
stockings or mechanical devices for
exercising the legs.
Higher percentages are
better. |
76% |
91% |
91% |
|
Heart Surgery Patients with
Controlled Blood Sugar After Surgery Percent of patients who
had surgery and who were measured as
having an appropriate (controlled) blood
sugar level the first and second day
following their surgery.
Higher percentages are
better. |
90% |
92% |
92% |
|
Surgery Patients
with Proper Hair Removal Percent of
patients that prior to having their surgery
had hair at the surgical site properly
removed.
Higher percentages are
better. |
99% |
99% |
99% |
*These data represent all hospitals across the United States that report
data to the Joint Commission for the
Accreditation of Healthcare Organizations (TJC).
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Children's
Asthma Care PERFORMANCE RESULTS
For a more detailed explanation of each of
the Children's Asthma Care Process of Care Quality Measures listed
below, visit the qualitycheck.org
website.
|
Children's Asthma Care
Quality Measures
|
|
Time Period: July 2008
through June 2009 |
|
Quality Measure |
Lee Memorial Health
System
|
Florida Hospital Average |
National Average* |
|
Use of Relievers for
Inpatient Asthma. Ages 2-17 years
Percent of Pediatric Asthma Patients
(age 2 through 17 years) who received
relievers during their hospitalization.
Higher percentages are
better. |
100% |
100% |
100% |
|
Use of Corticosteroids
for Inpatient Asthma. Ages 2-17 years
Percent of Pediatric Asthma Patients
(age 2 through 17 years) who received
corticosteroids during their
hospitalization.
Higher percentages are
better. |
99% |
99% |
99% |
|
Home Management Plan
of Care (HMPC) Given to
Patient/Caregiver
Percent of Pediatric Patients &/or
their Caregivers who were given a
written Home Management Plan of Care
document (HMPC)
Higher percentages are
better. |
75% |
69% |
56% |
*These data represent all hospitals across the United States that report
data to the Joint Commission for the Accreditation of Healthcare Organizations (TJC).
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