Washington Adventist Hospital | 23
Inpatient Quality Measures Table 5 shows composite scores of inpatient quality measures for WAH in 2012. A composite score of 96 percent or higher was achieved in each group. Because of overall high scores achieved within and across each of the measurement groups, differences between racial and ethnic groups were not calculated. TABLE 5. WAH INPATIENT QUALITY MEASURES - 2012
Measurement Group
Numerator
Denominator
Percentage
402
410
98.05%5
Heart Failure (HF)2
1209
1253
96.49%6
Acute Myocardial Infarction (AMI)3
2009
2013
99.80%7
Surgical Care Improvement Project (SCIP)4
5151
5228
98.53%8
Pneumonia Care (PN)
1
Measure group includes: PN-3a, PN-3b, PN-6, PN-6a, PN-6b, PN-PACS Measure group includes: HF-1, HF-2, HF-3, HF-PACS 3 Measure group includes: AMI-1, AMI-2, AMI-3, AMI-5, AMI-7a, AMI-8a, AMI-10, AMI-PACS 4 Measure group includes: SCIP-Card-2, SCIP-Inf-1a, SCIP-Inf-1b, SCIP-Inf-1c, SCIP-Inf-1d, SCIP-Inf-1e, SCIP-Inf-1f, SCIP-Inf-1g, SCIP-Inf-1h, SCIP-Inf-2a, SCIP-Inf-2b, SCIP-Inf-2c, SCIP-Inf-2d, SCIP-Inf-2e, SCIP-Inf-2f, SCIP-Inf-2g, SCIP-Inf-2h, SCIP-Inf-3a, SCIP-Inf-3b, SCIP-Inf-3c, SCIP-Inf-3d, SCIP-Inf-3e, SCIP-Inf-3f, SCIP-Inf-3g, SCIP-Inf-3h, SCIP-Inf-4, SCIP-Inf-6, SCIP-Inf-9, SCIP-PACS, SCIP-VTE-1, SCIP-VTE-2 5 Percentage range across individual measures for PN: 92.31%-100% 6 Percentage range across individual measures for HF: 98.87%-100% 7 Percentage range across individual measures for AMI: 99.53%-100% 8 Percentage range across individual measures for SCIP: 91.43%-100% 1 2
In October 2013, WAH was named as a Top Performer on Key Quality Measures® by The Joint Commission, meaning they achieved at least 95 percent compliance with certain measures for 2012 performance. At WAH, only three measures were found to have a score lower than 95 percent while 33 were found to have scores of 98 percent and above, 22 of which were perfect scores. Pneumonia Care (PN) Among six quality measures, the measure with the lowest success rate was initial antibiotic selection for PN in immunocompetent non-intensive care unit (ICU) patients with a percentage of 96.88 percent. However, due to a small sample size, the 3.12 percent rate of failure represents only two patients. All remaining measures had a rate of 97.18 percent and above including two with a rate of 100 percent. Heart Failure (HF) A total of four quality measures were evaluated for HF. Among them discharge instructions were provided to 93.49 percent of patients, angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blockers (ARB) for left ventricular systolic dysfunction (LVSD) were provided to 98.89 percent of patients for which it was indicated, and patient appropriateness of care compliance was found to have a rate of 94.27 percent. The fourth measure, Evaluation of left ventricular systolic (LVS) function, had a perfect completion rate of 100 percent. Acute Myocardial Infarction (AMI) Among the eight AMI measures, one was not indicated for any patients, and one—primary percutaneous coronary intervention (PCI) received within 90 minutes of hospital arrival—had a rate of 96.97 percent. Of the remaining six measures, two had a rate of 99.51 percent and above, while the other four had a rate of 100 percent.