Quality Reports

Quality Measure Definitions

(Higher scores are better, unless otherwise noted)

Heart Attack
Heart Failure
Pneumonia
Stroke Care
Surgery
Patient Satisfaction

Heart Attack Process of Care Measures	Brief Explanation of Treatment
ACEI/ARB given for cardiac (left ventricular systolic) dysfunction	ACEI (angiotensin converting enzyme inhibitors) and ARBs (angiotensin receptor blockers) are medicines used to treat heart attacks, heart failure, or a decreased function of the heart.
Given aspirin at arrival	Aspirin can help keep blood clots from forming and dissolve blood clots that can cause heart attacks.
Given aspirin at discharge	Taking aspirin may help prevent further heart attacks.
Given beta blocker at discharge	Beta blockers are a type of medicine used to lower blood pressure, treat chest pain (angina) and heart failure, and to help prevent a heart attack.
Given fibrinolytic within 30 minutes of arrival	Blood clots can cause heart attacks. Doctors may give a fibrinolytic or “clot busting” medicine, or perform a procedure to open the blockage.
Given PCI within 90 minutes of arrival	The procedures called Percutaneous Coronary Interventions (PCI) are among those that are the most effective for opening blocked blood vessels that cause heart attacks. Doctors may perform PCI, or give medicine to open the blockage, and in some cases, may do both.
Given smoking cessation advice	Smoking is linked to heart attacks. Quitting may help prevent another heart attack.
Heart attack death (mortality) within 30 days	The 30-day death rate includes death from any cause following hospitalization for heart attack, even if the cause of death is unrelated to the treatment for heart attack. Severity of illness is taken into account with this measure; however, patients requesting no aggressive treatment or resuscitation are not removed from the calculation. Lower scores are better.

Heart Failure Process of Care Measures	Brief Explanation of Treatment
ACEI/ARB given for cardiac (left ventricular systolic) dysfunction	ACEI (angiotensin converting enzyme inhibitors) and ARBs (angiotensin receptor blockers) are medicines used to treat heart attacks, heart failure, or a decreased function of the heart.
Evaluation of cardiac function	An evaluation of cardiac (left ventricular systolic) function checks how the left chamber of the heart is pumping.
Given discharge instructions	Information regarding heart failure management can help you better control your heart failure symptoms when you are discharged.
Given smoking cessation advice	Smoking is linked to heart failure. Quitting may help improve your condition.
Heart failure death (mortality) within 30 days	The 30-day death rate includes death from any cause following hospitalization for heart failure, even if the cause of death is unrelated to the treatment for heart failure. Severity of illness is taken into account with this measure; however, patients requesting no aggressive treatment or resuscitation are not removed from the calculation. Lower scores are better.

Pneumonia Process of Care Measures	Brief Explanation of Treatment
Given influenza vaccination	An influenza (flu) shot can help prevent influenza in the future.
Given pneumococcal vaccination	A pneumococcal (pneumonia) shot can help prevent pneumonia in the future. (This indicator will be retired in 2009)
Given initial antibiotic(s) within 6 hours after arrival	Timely use of antibiotics can improve the treatment of pneumonia caused by bacteria.
Given oxygenation assessment	Having enough oxygen in your blood is important to your health and recovery from pneumonia.
Given smoking cessation advice	Smoking is linked to pneumonia. Quitting reduces patient risk for the development of pneumonia.
Given the most appropriate initial antibiotic(s)	Antibiotics are medicines that treat infection, and each one is different. Antibiotics should be chosen that best treat the infection type for each pneumonia patient.
Initial Emergency Room blood culture performed prior to the first hospital dose of antibiotics	A blood culture tells what kind of medicine will work best to treat your pneumonia.
Pneumonia death (mortality) within 30 days	The 30-day death rate includes death from any cause following hospitalization for pneumonia, even if the cause of death is unrelated to the treatment for pneumonia. Severity of illness is taken into account with this measure; however, patients requesting no aggressive treatment or resuscitation are not removed from the calculation. Lower scores are better.

Stroke Care Measures	Brief Explanation of Treatment
Treatment to prevent blot clots	This measure tells how often stroke patients unable to walk within 48 hours receive treatment to prevent blood clots
Antithrombotics given within 48 hours	Antithrombotics are drugs that reduce the risk of recurrent stroke caused by blood flow blockages from clots.
Antithrombotics given on discharge	Antithrombotics are drugs that reduce the risk of recurrent stroke caused by blood flow blockages from clots.
Anticoagulants given for atrial fibrillation	Atrial fibrillation is a common heart arrhythmia and risk factor for stroke. Anticoagulation can be effective in preventing recurrent stroke in patients with atrial fibrillation when there are no medication contraindications.
Tissue plasminogen activator (t-PA), a clot-busting drug, considered	Certain patients, meeting strict criteria for the administration of this drug, within 3 hours of symptom onset, have been found to experience more rapid recovery and improved treatment outcomes.
Lipid-lowering drugs given for high lipid values	Elevated lipids are a risk factor for stroke which can be reduced through treatment with a lipid-lowering drug(s).
Screened for ability to swallow	Problems with swallowing can be identified through swallow screening. Screening prior to any oral intake reduces the risk of food and/or fluid entering the respiratory system.
Stroke education provided	Patient/family education should include information about stroke (its causes, treatment and risk factors) as well as desirable lifestyle modification.
Given smoking cessation advice	Smoking nearly doubles the risk of non-hemorrhagic stroke and is an alterable risk factor.
Plan for rehabilitation considered	Effective rehabilitation, initiated early following stroke, can in many instances, enhance recovery, prevent complications and minimize long-term disability

Surgical Care Measures	Brief Explanation of Treatment
Preventive antibiotic one hour before incision	Receiving an antibiotic within one hour before surgery reduces the risk of wound infections.
Appropriate preventive antibiotic for surgery	Certain antibiotics are recommended to help prevent wound infection for particular types of surgery.
Treatment to prevent blood clots within 24 hours of surgery	This measure tells how often surgery patients received treatment to prevent blood clots within 24 hours before or after certain surgeries.
Doctors ordered treatment to prevent blood clots	This measure tells how often surgery patients' doctors ordered treatment to prevent blood clots from forming in the veins after certain surgeries.
Preventive antibiotic stopped within 24 hours after surgery	It is important preventive antibiotics to be stopped within 24 hours after surgery to avoid side effects and other problems associated with antibiotic use. For certain surgeries, however, antibiotics may be needed for a longer time.

Patient Satisfaction Measures	Brief Explanation of Treatment
Communication with nurses	Patients report on how often their nurses communicated well with them, i.e., explained things clearly, listened carefully and treated the patient with courtesy and respect.
Communication with doctors	Patients report on how often their nurses communicated well with them, i.e., explained things clearly, listened carefully and treated the patient with courtesy and respect.
Help received quickly	Patients report on how often they were helped quickly when they used the call button or needed help in getting to the bathroom or using a bedpan.
Pain well controlled	Patients report on how well their pain was controlled and if hospital staff did everything they could to help with pain control.
Explanation of medications	Patients report on how often staff explained medicines they had not taken before, including what the medicines were for and what side effects they might have.
Room cleaning	Patients report how often the hospital room and bathroom were cleaned.
Room quiet	Patients report on how often the area around their room was quiet at night.
Discharge Instructions	Patients report on whether hospital staff discussed the help they would need at home, and if they were given written information about symptoms or health problems to watch for during their recovery.
Hospital rated as 9-10	Patients response to a separate question that asked for an overall rating of the hospital. Ratings were on a scale from 0 to 10, where “0” means “worst hospital possible” and “10” means “best hospital possible.”
WIllingness to recommend	The survey asked patients whether they would recommend the hospital to their friends and family.