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Quality Reports

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 was based primarily on data collected by Baxter Regional Medical Center January - December, 2014.

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


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
  • Data is from January to December, 2014

 

Core Measures Scorecard 2014

MeasureNumeratorDenominatorFacility Rate %
ADN Rate %
JC Rate %

CMS Rate %

Acute Myocardial Infarction (AMI)      
AMI-1 - Aspirin at Arrival 248 248 100.0 99.2 99.5 N/A
AMI-2 - Aspirin at Discharge 207 212 97.6 99.2 99.4 99.0
AMI-3 - ACEI or ARB for LVSD 36 38 94.7 99.4 98.2 N/A
AMI-5 - Beta-Blocker at Discharge 193 203 95.1 98.9 99.2 N/A
AMI-7a - Fibrinolytic within 30 Minutes 0 0 0.0 22.2 60.0 55.0
AMI-8a - PCI within 90 Minutes 35 39 89.7 95.6 96.2 96.0
AMI-10 - Statin at Discharge 171 198 86.4 97.0 98.9 98.0
Pneumonia (PN)      
PN-3a - Blood Cultures within 24 hrs for ICU pts 28 28 100.0 98.6 98.3 N/A
PN-3b - Blood Cultures in ED Prior to Antibiotics 130 133 97.7 96.0 98.1 N/A
PN-6 - Antibiotic Selection - Overall 83 87 95.4 94.2 95.6 96.0
Immunization (IMM) 0 0 0.0 0.0 0.0 n/A
IMM-1a - PN Immunization - Overall 724 797 90.8 92.7 92.6 N/A
IMM-1b - PN Immunization - Over 65 years 597 619 96.4 94.9 94.9 N/A
IMM-1c - PN Immunization - High Risk 127 198 71.3 88.2 87.4 N/A
IMM-2 - Influenza Immunization
543 547 99.3 94.0 95.9 93.0
Heart Failure (HF)      
HF-1 - Discharge Instructions 188 189 99.5 95.5 95.5 95.0
HF-2 - Evaluation of LVSF 248 252 98.4 97.6 99.6 99.0
HF-3 - ACEI or ARB for LVSD 56 67 83.6 95.6 97.5 97.0
Perinatal Care (PC) 0 0 0.0 0.0 0.0 N/A
PC-01 - Elective Delivery 0 34 0.0 4.2 3.3 5.0
PC-02 - Cesarean Section 48 107 44.9 26.9 26.5 N/A
PC-03 - Antenatal Steroids 0 0 0.0 46.6 85.3 N/A
PC-04 - Health Care Associated BSI 0 0 0.0 1.2 0.5 N/A
PC-05 - Exclusive Breast Milk Feeding 14 16 87.5 49.2 49.9 N/A
PC-05a - Exclusive Breast Milk Feeding Considering Mother's Choice 14 15 93.3 62.3 65.1 N/A
Surgical Care Improvement Project (SCIP)      
SCIP-Card-2 - Beta-Blocker Periop
192 195 98.5 96.1 98.2 98.0
SCIP-Inf-1a - Antibiotic Prior to Incision - Overall 356 362 98.3 98.1 99.0 99.0
SCIP-Inf-2a - Antibiotic Selection - Overall 353 361 97.8 97.7 98.7 99.0
SCIP-Inf-3a - Antibiotic Discontinued - Overall 300 315 95.2 92.4 98.3 98.0
SCIP-Inf-4 - Controlled Postop Glucose - Cardiac Surgery 85 89 95.5 96.8 98.4 94.0
SCIP-Inf-6 - Appropriate Hair Removal 509 510 99.8 99.9 99.9 N/A
SCIP-Inf-9 - Urinary Catheter Removed on POD 1 or 2 262 264 99.2 97.3 98.4 98.0
SCIP-Inf-10 - Periop Temperature Management 376 376 100.0 99.8 99.8 100.0
SCIP-VTE-2 - VTE Prophylaxis Received 301 302 99.7 99.5 99.8 99.0
Stroke (STK)   
STK-1 - VTE Prophylaxis 67 81 82.7 94.4 97.5 95.0
STK-2 - Discharged on Antithrombotic 78 79 98.7 98.2 99.4 99.0
STK-3 - Anticoagulation Therapy for A-Fib/Flutter 7 8 87.5 97.6 97.2 95.0
STK-4 - Thrombolytic Therapy
0 0 0.0 38.6 85.5 73.0
STK-5 - Antithrombotic Therapy By End of Hospital Day 2 94 96 97.4 95.5 98.6 98.0
STK-6 - Discharged on Statin 55 71 77.5 89.8 97.7 95.0
STK-8 - Stroke Education 32 33 97.0 91.2 94.7 90.0
STK-10 - Assessed for Rehab 81 83 97.6 97.5 98.7 98.0
Venous Thromboembolism (VTE)      
VTE-1 - VTE Prophylaxis 324 334 97.0 95.2 93.9 88.0
VTE-2 - ICU VTE Prophylaxis 139 144 96.5 96.0 96.9 94.0
VTE-3 - Overlap Therapy 38 43 88.4 92.0 96.1 94.0
VTE-4 - Heparin Monitoring 16 16 100.0 99.2 99.1 98.0
VTE-5 - Discharge Instructions 30 30 100.0 86.5 93.4 82.0
VTE-6 - Incidence of Potentially-Preventable VTE 0 5 0.0 6.1 4.5 8.0
Composite Score 7365 7784 94.6 93.9 N/A N/A
Appropriate Care Score 2542 2850 89.2 83.2 N/A N/A

* NOTE: Data for all populations and/or measures may not be available when selecting a timeframe that spans quarters.

* Composite Score is a representation of a facility's performance across several process measures. The scores for each selected measure are averaged and can be used to gauge adherence to treatment regimens.

* Appropriate Care Score is calculated by combining the selected measures to determine if ALL appropriate treatments were provided at the patient level. Evaluation of compliance "bundles" can lead to significant improvement in optimal patient care management.

 

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.

 

Download BRMC Core Measures Report here.

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