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Heart Attack
Heart Failure
Pneumonia
Surgical Infection Prevention
Indexes
Error Prevention
Inpatient Quality Indicators (IQI)
Patient Experience of Care Survey (HCAHPS Survey)
Birth
Birth Services - Clinical Services and Safety
Birth Services – Education and Support Services

Heart Attack

1.
 Aspirin at arrival – Percent of heart attack patients that receive an aspirin within 24 hours before or after arriving at the hospital
2.
 Aspirin at discharge – Percent of heart attack patients that are prescribed an aspirin when they are discharged from the hospital
3.
 Beta-blocker at discharge – Percent of heart attack patients that are prescribed a beta-blocker medication when they are discharged from the hospital
4.
 ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) – Percent of heart attack patients with low heart function that are prescribed an angiotensin converting enzyme inhibitor (ACE inhibitor) or angiotensin receptor blocker (ARB) medication when they are discharged from the hospital
5.
 Smoking Cessation Counseling – Percent of heart attack patients with a current or recent history of smoking cigarettes, who are given smoking cessation counseling during their hospital stay.
  6. Percutaneous Coronary Intervention (PCI) Performed With 90 Minutes of Arrival - Percent of heart attack patients given PCI within 90 Minutes after they arrive at hospital Detailed Technical Measures Specification
  7. Thrombolytic Medication Within 30 Minutes of Arrival - Percent of heart attack patients given thrombolytic medications within 30 minutes of arrival. Detailed Technical Measures Specification
Heart Failure
8.
 Left Ventricular Function (LVF) assessment – Percent of heart failure patients that are given a test to assess the function of their heart before, during or soon after discharge from the hospital
9.
 ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) – Percent of congestive heart failure patients with low heart function that are prescribed an angiotensin converting enzyme inhibitor (ACE inhibitor) or angiotensin receptor blocker (ARB) medication when they are discharged from the hospital
10.
 Smoking Cessation Counseling – Percent of heart attack patients with a current or recent history of smoking cigarettes, who are given smoking cessation counseling during their hospital stay.
11.
 Discharge Instructions – Percent of heart failure patients discharged to home with written instructions to the patient or caregiver that addresses all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.
Pneumonia
12.
 Pneumococcal screening and/or vaccination – Percent of patients 65 years and older admitted to the hospital with pneumonia that are asked if they had received a pneumococcal vaccination, and if they had not, received the vaccination prior to discharge from the hospital, if indicated.
13.
 Smoking Cessation Counseling – Percent of patients admitted to the hospital with pneumonia that have a current or recent history of smoking cigarettes, who are given smoking cessation counseling during their hospital stay.
14. Antibiotic < 6 hours of arrival - Percent of pneumonia patients admitted to hospital that receive antibiotics within 6 hours of their arrival at hospital Detailed Technical Measures Specification
15. Initial Antibiotic – Percent of immunocompetent patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines Detailed Technical Measures Specification
16. Blood Culture Collected – The percent of pneumonia patients who had their blood culture taken prior to their first dose of antibiotics. Detailed Technical Measures Specification
17. Flu Vaccine – Percent of patients discharged during October, November, December, January, or February with pneumonia, age 50 and older, who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated. Detailed Technical Measures Specification

Surgical Infection Prevention

18.
 Hip Surgery--Initial Antibiotic--Percent of hip surgery patients who received prophylactic antibiotics within one hour prior to surgical incision.
19.
 Hip Surgery – Appropriate Antibiotic – Percent of hip surgery patients who received prophylactic antibiotics recommended for their specific surgical procedure.
20.
 Hip Surgery – Stop Antibiotic – Percent of hip surgery patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
21.
 Knee Surgery – Initial Antibiotic – Percent of knee surgery patients who received prophylactic antibiotics within one hour prior to surgical incision.
22.
 Knee Surgery – Appropriate Antibiotic – Percent of knee surgery patients who received prophylactic antibiotics recommended for their specific surgical procedure.
23.
 Knee Surgery – Stop Antibiotic – Percent of knee surgery patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
24.
 Other Cardiac Surgery – Initial Antibiotic – Percent of other cardiac surgery patients who received prophylactic antibiotics within one hour prior to surgical incision.
25.
 Other Cardiac Surgery – Appropriate Antibiotic – Percent of other cardiac surgery patients who received prophylactic antibiotics recommended for their specific surgical procedure
 26. Other Cardiac Surgery – Stop Antibiotic – Percent of other cardiac surgery patients whose prophylactic antibiotics were discontinued within 48 hours after surgery end time. Detailed Technical Measures Specification
 27. Coronary Artery Bypass Graft (CABG) – Initial Antibiotic – Percent of CABG patients who received prophylactic antibiotics within one hour prior to surgical incision. Detailed Technical Measures Specification
 28. Coronary Artery Bypass Graft (CABG) – Appropriate Antibiotic – Percent of CABG surgery patients who received prophylactic antibiotics recommended for their specific surgical procedure. Detailed Technical Measures Specification
 29. Coronary Artery Bypass Graft (CABG) – Stop Antibiotic – Percent of CABG patients whose prophylactic antibiotics were discontinued within 48 hours after surgery end time. Detailed Technical Measures Specification
 30. Vascular Surgery – Initial Antibiotic – Percent of vascular surgery patients who received prophylactic antibiotics within one hour prior to surgical incision. Detailed Technical Measures Specification
 31. Vascular Surgery – Appropriate Antibiotic – Percent of vascular surgery patients who received prophylactic antibiotics recommended for their specific surgical procedure. Detailed Technical Measures Specification
 32. Vascular Surgery – Stop Antibiotic – Percent of vascular patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time. Detailed Technical Measures Specification
 33. Colon Surgery – Initial Antibiotic – Percent of colon surgery patients who received prophylactic antibiotics within one hour prior to surgical incision. Detailed Technical Measures Specification
 34. Colon Surgery – Appropriate Antibiotic – Percent of colon surgery patients who received prophylactic antibiotics recommended for their specific surgical procedure. Detailed Technical Measures Specification
 35. Colon Surgery – Stop Antibiotic – Percent of colon surgery patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time. Detailed Technical Measures Specification
 36. Hysterectomy Surgery – Initial Antibiotic – Percent of hysterectomy surgery patients who received prophylactic antibiotics within one hour prior to surgical incision. Detailed Technical Measures Specification
 37. Hysterectomy Surgery – Appropriate Antibiotic – Percent of hysterectomy surgery patients who received prophylactic antibiotics recommended for their specific surgical procedure. Detailed Technical Measures Specification
 38. Hysterectomy Surgery - Stop Antibiotic - Percent of hysterectomy surgery patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time. Detailed Technical Measures Specification
Indexes
39.
 Heart Attack Index - The percent of heart attack patients that had all the care they needed based on the process of care measures we collect for this condition.
40.
 Heart Failure Index - The percent of heart failure patients that had all the care they needed based on the process of care measures we collect for this condition.
41.
 Pneumonia Index - The percent of pneumonia patients that had all the care they needed based on the process of care measures we collect for this condition.
42.
 Surgical Infection Prevention Index - The percent of surgical patients that were given all the care they needed to prevent an infection based on selected measures.

In addition, CheckPoint measures individual hospital progress towards the following national goals to prevent errors in the hospital setting. These goals have been identified as key indicators of hospital safety by The Joint Commission.

Error Prevention

43.
 Procedure site marking – Percent that indicates the completeness of a process to mark the site of eligible surgical and invasive procedures that includes the patient in the site marking
44.
 Procedure verification process – Percent that indicate the completeness of a process to verify the correct patient, procedure(s) and site(s) prior to the start of all surgical or invasive procedures
45.
 Eliminate dangerous medication abbreviations – Percent that indicates progress toward the elimination of nine dangerous medication abbreviations, acronyms or symbols as defined by the Joint Commission on the Accreditation of Healthcare Organizations as being most likely to lead to an error.
46.
 Medication reconciliation upon admission – Percent that indicates progress towards obtaining the most accurate list of each patient's current medications and then, making sure that each medication is addressed when a patient is admitted to the hospital.

Inpatient Quality Indicators (IQI)

47.
 The Inpatient Quality Indicators include three distinct types of measures. Volume measures examine the volume of inpatient procedures for which a link has been demonstrated between the number of procedures performed and outcomes such as mortality. In-hospital mortality measures examine outcomes following procedures and for common medical conditions. Utilization examines procedures for which questions have been raised about overuse, underuse, and misuse.

There are many factors that determine the results in a mortality report. The data analysis method adjusts for some of these factors, but not all. For example, when a patient has a “Do Not Resuscitate (DNR)” order in place, the hospital must honor that, and our data analysis method cannot tell the difference between a death that occurs with a DNR order in place and one that occurs from some other cause.

Patient Experience of Care Survey (HCAHPS Survey)

48.
 The Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS) survey includes 27 questions that are used to report 10 measures (six summary, two individual and two global measures) that reflect the patient’s perception of the care that they have received in the hospital.

Birth

49.
 Pre-birth Steroids – Percent of preterm pregnancies that received at least one does of antenatal steroids.
50.
 Forceps Delivery – Percent of infants with a vaginal birth, delivered in a hospital where a forceps was used.
51.
 Vacuum Delivery – Percent of inborn deliveries with a vaginal birth where a vacuum extractor was used.
52.
 C-section with Labor – Percent of low-risk deliveries that labored and then had a caesarean birth.
53.
 C-section without Labor – Percent of low-risk deliveries that did not labor prior to a caesarean birth.
54.
 Breast Feeding – Percent of infants breast feeding at discharge. This measure includes exclusive breastfeeding plus a combination of breastfeeding plus other feedings.
55.
 Infant Composite – Percent of full term, live born infants without major congenital anomalies that met the National Center for Health Statistics significant birth injury criteria, had a 5 minute APGAR score less than 7, needed mechanical ventilation or resulted in neonatal death.

Birth Services - Clinical Services and Safety

56.
 # Births – Total number of births at a hospital in the last full calendar year.
57.
 24x7 Pain Med – Epidural pain medication is available 24 hours per day, 7 days per week.
58.
 Care Level – Level of care provided at the hospital based on the Academy of Pediatrics self assessment survey. Click here to See care levels.
59.
 Breastfeeding Specialist –Certified lactation consultant or certified lactation educator is available to assist with breast feeding.
60.
 Breastfeeding Specialist Available– Certified lactation consultant or certified lactation educator is available Monday-Friday only or 7 days per week.
61.
 Referral Arrangements – Referral arrangement is in place to transfer infants to a higher level of care when medically necessary.
62.
 Infant Security Assured – Hospital has a policy and procedure and/or safety equipment in place to minimize the risk of an infant abduction.
63.
 Adverse Scenario Drill – Hospital conducts an adverse clinical scenario drill at least annually.

Birth Services – Education and Support Services

64.
 Hospital provides education on the following topics
a. Breast feeding
b. Back to Sleep
c. Shaken baby syndrome
d. Care seat use
e. Infant immunizations
f. Weight control for mothers after delivery
g. Family planning for next pregnancy
h. Post delivery mood disorders
i. Smoking cessation

No data collected at this time or no cases met criteria?

See "Low Reporting Volume."

Data collected, but the report shows a "+" sign in the report?

See "Low Reporting Volume."

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