Lee Memorial Health System's Quality Reports - National Quality Improvement Goals

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:

Heart Attack Care
Heart Failure Care
Pneumonia Care
Surgical Care Infection Prevention

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 2006 through June 2007.

Heart Attack Care PERFORMANCE RESULTS

For a more detailed explanation of each of the Heart Attack Care Quality Measures listed below, visit the hospitalcompare.hhs.gov or qualitycheck.org websites.

Heart Attack Care Quality Measures
Time Period: January 2007 through December 2007
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.	93%	97%	97%
Aspirin at Discharge Heart attack patients who receive a prescription for aspirin when discharged from the hospital. Higher percentages are better.	93%	96%	97%
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%	90%	92%
Beta Blocker on Arrival Heart attack patients who receive a medicine called a "beta blocker" when they arrive at the hospital. Higher percentages are better.	90%	94%	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.	96%	97%	97%
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.	59%	69%	72%
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.	98%	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).

Heart Failure Care PERFORMANCE RESULTS

For a more detailed explanation of each of the Heart Failure Care Quality Measures listed below, visit the hospitalcompare.hhs.gov or qualitycheck.org websites.

Heart Failure Care Quality Measures
Time Period: January 2007 through December 2007
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.	96%	96%	95%
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.	79%	89%	90%
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.	53%	77%	77%
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%	98%	96%

*These data represent all hospitals across the United States that report data to the Joint Commission for the Accreditation of Healthcare Organizations (TJC).

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: January 2007 through December 2007
Quality Measure	Lee Memorial Health System	Florida Hospital Average	National Average*
Oxygenation assessment Pneumonia inpatients who receive an oxygenation assessment, arterial blood gas (ABG), or pulse oximetry within 24 hours of hospital arrival. Higher percentages are better.	100%	100%	100%
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.	91%	92%	93%
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.	79%	86%	84%
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%	90%	91%
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.	95%	94%	93%
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.	94%	96%	94%
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.**	78%	78%	79%
Pneumonia Seasonal Measure - Reporting Period: December 2007 - February 2008**
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.	62%	66%	64%
Initial antibiotic selection for 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.	89%	92%	92%

* 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: January 2007 through December 2007
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.	71%	90%	89%
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.	95%	93%	95%
Preventative Antibiotic(s) Discontinued 24 Hours After Surgery Percent of patients who had surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended. Higher percentages are better.	78%	84%	85%

*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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