Quality Scorecards

Use the Quality Scorecards below to see how we are doing in each area. More information can be found by clicking the tips within the scorecard. Click on a measurement title to view a detailed graph of that Measure.

Scorecard item Current Target Period
Outcomes
Acute MI (Heart Attack) All-or-None Bundle 100 100 Q3
CY2013
Heart Failure All-or-None Bundle 99.2 100 Q3
CY2013
Pneumonia All-or-None Bundle 100 100 Q3
CY2013
SCIP All-or-None Bundle 96.7 100 Q3
CY2013
VTE  (All or None Bundle Compliance)  90 90

Q3
CY2013

Stroke (All or None Bundle Compliance) 91 90 Q3
CY2013
*30 Day Readmission Rate - AMI (Heart Attack) 5.9 7.84 Dec
2013
*30 Day Readmission Rate - Heart Failure 13.4 14.87 Dec
2013
*30 Day Readmission Rate - Pneumonia 10.96 10.95 Dec
2013
Median time of ED Arrival to ED Departure for IP Admit 320 272 Dec
2013
Median time of decision to ED departure for IP Admit 111 92 Dec
2013
Safety
Mortality Index 0.83 1.0 Q3
CY2013
Medication Events with Harm 5.93 2.65 Dec
2013
Catheter Associated Urinary Tract Infection 3.2 1.14 Dec
2013
Efficiency
Patients leaving the Emergency Department without being seen 1.4 2.0 Dec
2013
Service / Patient Satisfaction: (Percentile Ranking)
"Willingness to recommend this Hospital?" 81% 90% Q3
CY2013
Learning Organization
Completion of Communication In Healthcare: All Staff 72%   Dec
2013
Completion of Quality Essentials: All Staff 19%   Dec
2013
Scorecard item Current Target Period
Outcomes
Acute MI (Heart Attack) All-or-None Bundle 100 100 Q3
CY2013
Heart Failure All-or-None Bundle 94.4 100 Q3
CY2013
 
Pneumonia All-or-None Bundle 100 100 Q3
CY2013
 
SCIP All-or-None Bundle 100 100 Q3
CY2013
VTE  (All or None Bundle Compliance) 93.6 90 Q3
2013
Stroke (All or None Bundle Compliance) 50 90 Q3
CY2013
*30 Day Readmission Rate - AMI (Heart Attack) 0 0 Dec
2013
*30 Day Readmission Rate - Heart Failure 14.29 0 Dec
2013
*30 Day Readmission Rate - Pneumonia 20 0 Dec
2013
Median time of ED Arrival to ED Departure for IP Admit 289 205 Dec
2013
Median time of decision to ED departure for IP Admit 146 50 Dec
2013
Safety
Mortality Index 1.54 1.0 Q3
CY2013
Medication Events with Harm 0 0 Dec
2013
Efficiency
Patients leaving the Emergency Department without being seen 1.72 2.0 Dec
2013
Service / Patient Satisfaction: (Percentile Ranking)
"Willingness to recommend this Hospital?" 57% 90% Q3
CY2013
 
Learning Organization

Completion of Communication In Healthcare: All Staff

53%   Dec
2013
Completion of Quality Essentials: All Staff 81%   Dec
2013
Scorecard item Current Target Period
Outcomes
Acute MI (Heart Attack) All-or-None Bundle 100 100 Q3
CY2013
Heart Failure All-or-None Bundle 100 100 Q3
CY2013
Pneumonia All-or-None Bundle 96.3 100 Q3
CY2013
SCIP All-or-None Bundle 100 100 Q3
CY2013
VTE  (All or None Bundle Compliance) 94.2 90 Q3
CY2013
Stroke (All or None Bundle Compliance) 100 90 Q3
CY2013
*30 Day Readmission Rate - AMI (Heart Attack) 0 0 Dec
2013
*30 Day Readmission Rate - Heart Failure 0 0 Dec
2013
*30 Day Readmission Rate - Pneumonia 8.33 0 Dec
2013
Median time of ED Arrival to ED Departure for IP Admit 233 205 Dec
2013
Median time of decision to ED departure for IP Admit 57 50 Dec
2013
Safety
Mortality Index 1.1 1.0 Q3
CY2013
Medication Events with Harm 0 0 Dec
2013
Efficiency
Patients leaving the Emergency Department without being seen 0.6 2.0 Dec
2013
Service / Patient Satisfaction: (Percentile Ranking)
"Willingness to recommend this Hospital?" 54% 90% Q3
CY2013
Learning Organization
Completion of Communication In Healthcare: All Staff
69%   Dec
2013
Completion of Quality Essentials: All Staff 84%   Dec
2013
Scorecard item Current Target Period
Outcomes
Acute MI (Heart Attack) All-or-None Bundle 100 100 Q3
CY2013
Heart Failure All-or-None Bundle 100 100 Q3
CY2013
Pneumonia All-or-None Bundle 94.7 100 Q3
CY2013
SCIP All-or-None Bundle 90.9 100 Q3
CY2013
VTE  (All or None Bundle Compliance) 97 90 Q3
CY2013
Stroke (All or None Bundle Compliance) 90.9 90 Q3
CY2013
*30 Day Readmission Rate - AMI (Heart Attack) 0 0 Dec
2013
*30 Day Readmission Rate - Heart Failure 0 0 Dec
2013
*30 Day Readmission Rate - Pneumonia 14.29 0 Dec
2013
Median time of ED Arrival to ED Departure for IP Admit 278 205 Dec
2013
Median time of decision to ED departure for IP Admit 49 50 Dec
2013
Safety
Mortality Index 0.87 1.0 Q3
CY2013
Medication Events with Harm 3.22 0 Aug
2013
Efficiency
Patients leaving the Emergency Department without being seen 2.1 2.0 Dec
2013
Service / Patient Satisfaction: (Percentile Ranking)
"Willingness to recommend this Hospital?" 33% 90% Q3
CY2013
Learning Organization
Completion of Communication In Healthcare: All Staff 81%   Dec
2013
Completion of Quality Essentials: All Staff 80%   Dec
2013
Scorecard item Current Target Period
Outcomes
Acute MI (Heart Attack) All-or-None Bundle 100 100 Q3
CY2013
Heart Failure All-or-None Bundle 100 100 Q3
CY2013
Pneumonia All-or-None Bundle 100 100 Q3
CY2013
SCIP All-or-None Bundle 96.8 100 Q3
CY2013
VTE  (All or None Bundle Compliance) 94.4 90 Q3
CY2013
Stroke (All or None Bundle Compliance) 100 90 Q3
CY2013
*30 Day Readmission Rate - AMI (Heart Attack) 0 0 Dec
2013
*30 Day Readmission Rate - Heart Failure 0 0 Dec
2013
*30 Day Readmission Rate - Pneumonia 9.09 0 Dec
2013
Median time of ED Arrival to ED Departure for IP Admit 241 205 Dec
2013
Median time of decision to ED departure for IP Admit 56 50 Dec
2013
Safety
Mortality Index 1.32 1.0 Q3
CY2013
Medication Events with Harm 1.62 0 Dec
2013
Efficiency
Patients leaving the Emergency Department without being seen 1.6 2.0 Dec
2013
Service / Patient Satisfaction: (Percentile Ranking)
"Willingness to recommend this Hospital?" 48.5% 90% Q3
CY2013
Learning Organization
Completion of Communication In Healthcare: All Staff
66%   Dec
2013
Completion of Quality Essentials: All Staff 63%   Dec
2013

* Readmission Rate Targets are set based upon hospital bed size

Last Updated 03/26/2013