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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, 2012.

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
  • January - December, 2012


Core Measures Scorecard 2012

MeasureNumeratorDenominatorFacility Rate %
ADN Rate %
JC Rate %

CMS Rate %

Acute Myocardial Infarction (AMI)      
AMI-1 - Aspirin at Arrival 269 270 99.6 98.6 99.4 99.0
AMI-2 - Aspirin at Discharge 225 230 97.8 98.5 99.2 99.5
AMI-3 - ACEI or ARB for LVSD 49 53 92.5 95.7 97.7 97.0
AMI-5 - Beta-Blocker at Discharge 227 229 99.1 98.5 99.2 99.0
AMI-7a - Fibrinolytic within 30 Minutes 0 0 0 66.7 74.3 58.0
AMI-8a - PCI within 90 Minutes 35 37 94.6 95.9 95.0 92.0
AMI-10 - Statin at Discharge 188 218 86.2 95.0 98.3 97.0
Pneumonia (PN)      
PN-3a - Blood Cultures within 24 hrs for ICU pts 17 17 100.0 94.1 98.2 N/A
PN-3b - Blood Cultures in ED Prior to Antibiotics 133 136 97.8 96.3 97.8 96.0
PN-6 - Antibiotic Selection - Overall 93 99 93.9 92.4 96.4 94.0
Heart Failure (HF)      
HF-1 - Discharge Instructions 214 215 99.5 94.8 94.2 90.0
HF-2 - Evaluation of LVSF 275 279 98.6 97.1 99.4 98.0
HF-3 - ACEI or ARB for LVSD 92 101 91.1 95.1 97.1 95.0
Surgical Care Improvement Project (SCIP)      
SCIP-Card-2 - Surgery Patients on Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker During the Perioperative Period 219 222 98.6 94.5 97.2 95.0
SCIP-Inf-1a - Antibiotic Prior to Incision - Overall 372 380 97.9 97.9 98.6 97.0
SCIP-Inf-2a - Antibiotic Selection - Overall 375 379 98.9 98.4 98.8 98.0
SCIP-Inf-3a - Antibiotic Discontinued - Overall 350 367 95.4 97.0 97.6 96.0
SCIP-Inf-4 - Controlled Postop Glucose - Cardiac Surgery 104 110 94.5 96.6 96.3 94.0
SCIP-Inf-6 - Appropriate Hair Removal 507 508 99.8 99.8 99.9 100.0
SCIP-Inf-9 - Urinary Catheter Removed on POD 1 or 2 293 317 92.4 92.8 96.2 92.0
SCIP-VTE-1 - VTE Prophylaxis Ordered 306 312 98.1 94.7 98.4 95.0
SCIP-VTE-2 - VTE Prophylaxis Received 301 312 96.5 96.8 97.8 94.0
SCIP-Inf-10 - Periop Temperature Management 389 390 99.7 99.5 99.7 99.0
Venous Thromboembolism (VTE)      
VTE-1 - VTE Prophylaxis 373 444 84.0 83.5 89.7 N/A
VTE-2 - ICU VTE Prophylaxis 90 95 94.7 89.5 95.3 N/A
VTE-3 - Overlap Therapy 46 62 74.2 81.1 94.6 N/A
VTE-4 - Heparin Monitoring 18 18 100.0 97.3 98.9 N/A
VTE-5 - Discharge Instructions 44 49 89.8 78.4 81.4 N/A
VTE-6 - Incidence of Potentially-Preventable VTE 1 6 16.7 14.7 3.8 N/A
Composite Score 5603 5855 95.7 94.6 N/A N/A
Appropriate Care Score 1589 1815 87.5 86.6 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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