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Measures for Pneumonia Diagnosis
This table shows our percentage of compliance with every patient care standard
being measured. A score of 91% means we were compliant with patient
care best practices 91% of the time.
This table illustrates measures for past fiscal years and for each quarter
of the current fiscal year. It shows our percentage of compliance
with patient care best practices for adults diagnosed with pneumonia.
| Core Measures (Reported
for recently available quarter: FY10 Q2 ) |
TRENDED QUALITY DATA
(Most recent 4 years) |
|
(Most recent 4 quarters) |
| University Hospital Pneumonia Care Quality Measures |
FY07
(Jul 06 - Jun 07) |
FY08**
(Jul 07 - Mar 08) |
FY09**
(Jul 08 - Dec 08) |
FY10 (Jul -
Dec 09) |
|
FY09 Q3
(Jan 09 -
Mar 09) |
FY09 Q4
(Apr 09-
Jun 09) |
FY10 Q1
(Jul 09 -
Sep 09) |
FY10 Q2
(Oct 09 -
Dec 09) |
Benchmark*
(Jul 08 -
Jun 09) |
| |
CMS Validated+ |
√ |
√ |
√ |
|
|
√ |
√ |
|
|
|
| PN-2 |
Pneumococcal Vaccination (%) |
67% |
76% |
75% |
78% |
|
67% |
93% |
73% |
83% |
91% |
| PN-3a |
Blood Cultures 24 prior to / after arrival - ICU (%) |
|
96% |
96% |
100% |
|
90% |
100% |
100% |
100% |
n/a |
| PN-3b |
Blood Cultures in ED prior to Initial Antibotic (%) |
93% |
94% |
94% |
100% |
|
100% |
87% |
100% |
100% |
94% |
| PN-4 |
Adult Smoking Cessation Advice/Counseling
(%) |
95% |
91% |
95% |
95% |
|
100% |
100% |
100% |
92% |
95% |
| PN-5c |
Antibiotic w/in 6 hours of Arrival
(%) |
n/a |
91% |
87% |
83% |
|
100% |
58% |
87% |
80% |
95% |
| |
Perfect Score ** Patients who had all elements of care done correctly for the treatment of Pneumonia. |
60% |
68% |
71% |
77% |
|
82% |
81% |
84% |
70% |
|
| |
Pneumonia Composite Score
The "Composite Score Approach" = the sum of the numerators
for each measure divided by the sum of the denominators for each
measure times 100.. |
89% |
90% |
92% |
94% |
|
97% |
93% |
96% |
94% |
|
+ The Centers for Medicare and Medicaid (CMS) audits
a sample of patient records to make sure that reported numbers are accurate.
The CMS process lags several months behind and so our most recent results
have not been validated by CMS yet. Our validation scores are consistently
good and we anticipate that the results shown accurately reflect performance
for that interval.
* Benchmark from Centers for Medicare and Medicaid - HHS Hospital Compare website,
most current benchmark for Ohio
*** Effective October, 2007, the Pneumonia Composite Score includes only Antibotic within 6 hours rather than 4 and 8 hours (per CMS change). Scores were re-calculated to reflect this change.
| Core
Measures (Reported for recently available quarter: FY10 Q2 ) |
CURRENT QUALITY SCORES FOR UC HEALTH |
All UC Health
Pneumonia Care Quality Measures |
University Hospital |
West Chester Medical Center |
Benchmark*
(Jul 08-
Jun 09) |
| PN-1 |
Oxygenation Assessment (%) |
100% |
94% |
91% |
| PN-2 |
Pneumococcal Vaccination (%) |
60% |
100% |
n/a |
| PN-3b |
Blood Cultures Performed Before First
Antibiotic Received (%) |
97% |
94% |
94% |
| PN-4 |
Adult Smoking Cessation Advice/Counseling
(%) |
100% |
78% |
95% |
| PN-5c |
Antibiotic w/in 6hours of Arrival
(%) |
97% |
96% |
95% |
| |
Perfect Score ** Patients who had all elememts of care done correctly for the treatment of Pneumonia. |
71% |
67% |
|
| |
Pneumonia Composite Score
The "Composite Score Approach" = the sum of the numerators
for each measure divided by the sum of the denominators for each
measure times 100. |
95% |
92% |
|
* Benchmark from Centers for Medicare and Medicaid
- HHS Hospital Compare website, most current benchmark for Ohio.
** Includes Christ and St. Luke Hospitals through June, 2007. Includes Jewish and Fort Hamilton Hospitals through June 2008. FY2009 & FY2010 includes only University Hospital and West Chester Medical Center data.
Oxygenation assessment
Having enough oxygen in your blood is important to your health.
- This measure shows the percent of pneumonia patients who receive
an oxygenation assessment, arterial blood gas (ABG), or pulse oximetry
within 24 hours of hospital arrival.
Pneumococcal vaccination
A pneumonia (pneumococcal) shot can help prevent pneumonia in the future,
even for patients who have been hospitalized for pneumonia.
- This measure shows the percent of pneumonia patients age 65 and older
who were screened for pneumococcal vaccine status and were administered
the vaccine prior to discharged, if indicated.
Blood cultures performed before first antibiotic received
A blood culture tells what kind of medicine will work best to treat patients’ pneumonia.
- This measure shows the percent of pneumonia patients whose blood
culture specimen was collected prior to first hospital dose of antibiotics.
Adult smoking cessation advice/ counseling
Smoking is linked to pneumonia. Quitting may help prevent getting pneumonia
again.
- This measure shows the percent of pneumonia patients with a history
of smoking cigarettes, who are given smoking cessation advice or counseling
during a hospital stay.
Antibiotic w/in 8 hours of arrival
Timely use of antibiotics can improve the treatment of pneumonia caused
by bacteria.
- This measure shows the percent of pneumonia patients that receive
within 8 hours after arrival at the hospital.
Antiobiotic w/in 4 hours of arrival
Timely use of antibiotics can improve the treatment of pneumonia caused
by bacteria.
- This measure shows the percent of pneumonia patients that receive
within 4 hours after arrival at the hospital.
Using the tables as a guide for these three areas, you can see our progress
year to year and quarter to quarter.
If you have any questions about the information provided on this site,
please contact Health Alliance Quality Management Services at QualityManagementServices@healthall.com.
Blood / Cardiovascular
