Baxter Regional Medical Center

Thursday March 11, 2010

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Quality Report

BRMC’s Commitment to Quality

At Baxter Regional Medical Center, we are committed to communicating openly with our community. We are pleased to share our quality report with you. This report compares our performance in key areas of healthcare and service to that of other regional and national hospitals. These quality measures are tracked in association with a program coordinated by the Centers for Medicare and Medicaid Services. Our participation in this national initiative is an indication of our ongoing efforts to improve quality care.

At Baxter Regional, our physicians, nurses and clinical professionals are dedicated to meeting the healthcare needs of Twin Lakes area residents. Our collective goal is a positive patient experience. The following information is an accurate and honest report about the quality of care we provide at Baxter Regional.

This data, based primarily on data collected by Baxter Regional Medical Center hospital from April 2007 through March 2008, was released publicly on December 18, 2008.  

Click on the condition below that you wish to review. You will then be presented with a list of quality measures from which to choose.

 

Condition Description
Heart Attack (AMI) Care A heart attack (also referred to as acute myocardial infarction or AMI) occurs when the arteries leading to the heart become blocked and the blood supply is slowed or stopped. These quality measures show some of the standards of care provided, if appropriate, to someone experiencing a heart attack.
Heart Failure Care Heart failure is a weakening of the heart’s pumping power. When the heart fails, the body doesn’t get enough oxygen and nutrients to operate properly. These quality measures show some of the standards of care provided, if appropriate, to someone experiencing heart failure.
Pneumonia Care Pneumonia is caused by a viral or bacterial infection or inflammation that fills the lungs with fluid. This lowers the oxygen level in the blood. These quality measures show some of the standards of care provided, if appropriate, to someone suffering from pneumonia.
SCIP The Surgical Care Improvement Project (SCIP) is a national quality-improvement project designed to improve surgical care in hospitals. Hospitals can reduce the risk of surgical infection by following proven surgical care standards. These quality measures show the postsurgical standards of care provided at BRMC.

HCAHPS

Hospital Consumer Assessment of Health Plan Surveys
http://www.hospitalcompare.hhs.gov/

  • HCAHPS is a tool to be used for public reporting of major areas of hospital performance to support consumer choice.
  • Focus: Physicians, nurse, pain management, medications, toileting, discharge
  • Who receives the survey?
  • Inpatients only: overnight stays, 18 years or older, random, not based on payor source
  • CMS requires at least 300 surveys returned per year
  • October 1, 2006 to June 30, 2007


BAXTER REGIONAL MEDICAL CENTER
Results from date range: July 2008 through June 2009
 
Your Hospital's Adjusted Score
CMS State Average
CMS U.S. Average
HCAHPS Composites
Communication with Nurses (% Always)
73
76
75
Communication with Doctors (% Always)
76
83
80
Responsiveness of Hospital Staff (% Always)
62
65
63
Pain Management (% Always)
68
70
68
Communication About Medicines (% Always)
57
60
59
Hospital Environment Items
Cleanliness of Hospital Environment (% Always)
72
69
70
Quietness of Hospital Environment (% Always)
59
64
57
Discharge Information Composite
Discharge Information (% Yes)
82
78
81
Global Items
Overall Rating (% 9 & %10)
65
65
65
Willingness to Recommend (% Definitely Yes)
68
67
68

 

Results from date range: July 2008 through June 2009

2009 Core Measures Scorecard

  • Core Measure
    BRMC Goal
    Oct
    Nov
    Dec
    Jan
    Feb
    Mar
    Apr
    May
    June
    July 
    Aug 
    Sep
    YTD
    Acute MI
    # of cases
    17
    23
    10
    50
    # with appropriate & documented care
    16
    22
    10
    48
    Aspirin at arrival
    95%
    94%
    96%
    100%
    		                  
    96%
    # of cases
    21
    27
    16
    64
    # with appropriate  & documented care
    17
    25
    15
    57
    Aspirin prescribed at discharge
    95%
    81%
    93%
    94%
    		                  
    89%
    # of cases
    9
    8
    6
    23
    # with appropriate  & documented care
    8
    6
    5
    19
    ACE/ARB for LVSD
    95%
    89%
    75%
    83%
    		                  
    83%
    # of cases
    12
    5
    7
    24
    # with appropriate  & documented care
    12
    5
    7
    24
    Adult smoking cessation
    advice/counseling
    95%
    100%
    100%
    100%
    		                  
    100%
    # of cases
    17
    19
    14
    50
    # with appropriate  & documented care
    16
    19
    14
    49
    Beta Blocker at discharge
    95%
    94%
    100%
    100%
    		                  
    98%
    # of cases
    12
    15
    8
    35
    # with appropriate  & documented care
    11
    15
    7
    33
    Beta Blocker at arrival
    95%
    92%
    100%
    88%
    		                  
    94%
    # of cases
    6
    9
    0
    15
    # with appropriate  & documented care
    6
    9
    0
    15
    PTCA received within
    90 minutes of hospital
    93%
    100%
    100%
    		                    
    100%
  • Core Measure
    National Average
    Oct
    Nov
    Dec
    Jan
    Feb
    Mar
    Apr
    May
    Jun
    July
    Aug 
    Sep
    YTD
    Pneumonia
    # of cases
    37
    29
    39
    105
    # with appropriate & documented care
    37
    29
    39
    105
    Oxygenation  Assessment
    95%
    100%
    100%
    100%
    		                  
    100%
    # of cases
    32
    19
    22
    73
    # with appropriate & documented care
    30
    19
    22
    71
    Pneumococcal Vaccination  **
    95%
    94%
    100%
    100%
    		                  
    97%
    # of cases
    29
    24
    35
    88
    # with appropriate & documented care
    28
    22
    34
    84
    Blood culture performed in ER prior  to 1st antibiotics 
    95%
    97%
    92%
    97%
    		                  
    95%
    # of cases
    8
    8
    11
    27
    # with appropriate & documented care
    8
    8
    11
    27
    Smoking cessation advice/counseling **
    95%
    100%
    100%
    100%
    		                  
    100%
    # of cases
    31
    25
    32
    88
    # with appropriate & documented care
    30
    23
    30
    83
    Initial antibiotic received within 6 hours arrival**
    95%
    97%
    92%
    94%
    		                  
    94%
    # of cases
    21
    15
    27
    63
    # with appropriate & documented care
    17
    14
    24
    55
    Initial antibiotic selection for immunocompetent pts
    95%
    81%
    93%
    89%
    		                  
    87%
    # of cases
    39
    25
    39
    103
    # with appropriate & documented care
    32
    25
    38
    95
    Influenza Vaccination
    95%
    82%
    100%
    97%
    		                  
    92%

    ** = Medicaid Project Measure

  • Core Measure
    BRMC Goal
    Oct
    Nov
    Dec
    Jan
    Feb
    Mar
    Apr
    May
    Jun
    July
    Aug 
    Sep
    YTD
    Heart Failure
    # of cases
    22
    16
    23
    14
    75
    # with appropriate & documented care
    17
    13
    22
    13
    65
    Discharge Instructions **
    95%
    77%
    81%
    96%
    93%
    87%
    # of cases
    26
    23
    28
    21
    98
    # with appropriate & documented care
    22
    20
    26
    21
    89
    Evaluation of EF **
    95%
    85%
    87%
    93%
    100%
    91%
    # of cases
    10
    9
    9
    8
    36
    # with appropriate & documented care
    9
    7
    8
    7
    31
    ACE/ARB for LVSD **
    95%
    90%
    78%
    89%
    88%
    86%
    # of cases
    4
    1
    4
    3
    12
    # with appropriate & documented care
    4
    1
    4
    3
    12
    Smoking cessation advice/counseling
    95%
    100%
    100%
    100%
    100%
    100%
  • Core Measure
    BRMC Goal
    Oct
    Nov
    Dec
    Jan
    Feb
    Mar
    Apr
    May
    June
    July
    Aug 
    Sep
    YTD
    SCIP
    # of cases
    48
    50
    45
    143
    # with appropriate & documented care
    48
    49
    45
    142
    Antibiotics consistent with current recommendations
    95%
    100%
    98%
    100%
    99%
     
    # of cases
    43
    48
    45
    136
    # with appropriate & documented care
    41
    42
    41
    124
    Antibiotics d/c’d within 24 hours of surgery end time**
    95%
    95%
    88%
    91%
    91%
     
    # of cases
    11
    14
    10
    35
    # with appropriate & documented care
    11
    14
    10
    35
    VTE prophylaxis ordered during admission **
    95%
    100%
    100%
    100%
    100%
     
    # of cases
    11
    14
    10
    35
    # with appropriate & documented care
    11
    14
    10
    35
    VTE prophylaxis  ordered within 24hrs **
    95%
    100%
    100%
    100%
    100%
     
    # of cases
    11
    14
    8
    33
    # with appropriate & documented care
    11
    14
    8
    33
    Cardiac controlled  6am postop serum glucose
    95%
    100%
    100%
    100%
    100%
     
    # of cases
    63
    66
    59
    188
    # with appropriate & documented care
    63
    62
    59
    184
    Appropriate hair removal
    95%
    100%
    94%
    100%
    98%
     
    # of cases
    7
    5
    4
    16
    # with appropriate & documented care
    6
    5
    4
    15
    Postop normothermia
    95%
    86%
    100%
    100%
    94%
     
    # of cases
    26
    25
    20
    71
    # with appropriate & documented care
    26
    25
    18
    69
    Perioperative beta blockers
    95%
    100%
    100%
    90%
    97%
    # of cases
    48
    49
    45
    142
    # with appropriate & documented care
    47
    49
    44
    140
    Antibiotics within 1 hour of incision
    95%
    98%
    100%
    98%
    99%