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 98.75 100 Q1
CY2014
Heart Failure All-or-None Bundle 95.24 100 Q1
CY2014
Pneumonia All-or-None Bundle 100 100 Q1
CY2014
SCIP All-or-None Bundle 98.28 100 Q1
CY2014
VTE  (All or None Bundle Compliance)  90.31 90

Q1
CY2014

Stroke (All or None Bundle Compliance) 92.61 90 Q1
CY2014
*30 Day Readmission Rate - AMI (Heart Attack) 6.60 7.84 June
2014
*30 Day Readmission Rate - Heart Failure 12.70 14.87 June
2014
*30 Day Readmission Rate - Pneumonia 16.30 10.95 June
2014
Median time of ED Arrival to ED Departure for IP Admit 314 272 June
2014
Median time of decision to ED departure for IP Admit 90 92 June
2014
Safety
Mortality Index 0.83 1.0 Q1
CY2014
Medication Events with Harm 5.52 2.65 June
2014
Catheter Associated Urinary Tract Infection 3.08 1.14 June
2014
Efficiency
Patients leaving the Emergency Department without being seen 5.30 2.0 June
2014
Service / Patient Satisfaction: (Percentile Ranking)
"Willingness to recommend this Hospital?" 83.8% 90% Q1
CY2014
Learning Organization
Completion of Communication In Healthcare: All Staff 5403 4170 June
2014
Completion of Quality Essentials: All Staff 1772 4170 June
2014
Scorecard item Current Target Period
Outcomes
Acute MI (Heart Attack) All-or-None Bundle 100 100 Q1
CY2014
Heart Failure All-or-None Bundle 100 100 Q1
CY2014
 
Pneumonia All-or-None Bundle 92.31 100 Q1
CY2014
 
SCIP All-or-None Bundle 100 100 Q1
CY2014
VTE  (All or None Bundle Compliance) 96.88 90 Q1
CY2014
Stroke (All or None Bundle Compliance) 70.00 90 Q1
CY2014
*30 Day Readmission Rate - AMI (Heart Attack) 0 0 June
2014
*30 Day Readmission Rate - Heart Failure 0 0 June
2014
*30 Day Readmission Rate - Pneumonia 0 0 June
2014
Median time of ED Arrival to ED Departure for IP Admit 366 205 June
2014
Median time of decision to ED departure for IP Admit 85 50 June
2014
Safety
Mortality Index 1.42 1.0 Q1
CY2014
Medication Events with Harm 0 0 June
2014
Efficiency
Patients leaving the Emergency Department without being seen 2.35 2.0 June
2014
Service / Patient Satisfaction: (Percentile Ranking)
"Willingness to recommend this Hospital?" 40.9% 90% Q1
CY2014
 
Learning Organization

Completion of Communication In Healthcare: All Staff

262 256 June
2014
Completion of Quality Essentials: All Staff 331 256 June
2014
Scorecard item Current Target Period
Outcomes
Acute MI (Heart Attack) All-or-None Bundle 100 100 Q1
CY2014
Heart Failure All-or-None Bundle 100 100 Q1
CY2014
Pneumonia All-or-None Bundle 100 100 Q1
CY2014
SCIP All-or-None Bundle 96.30 100 Q1
CY2014
VTE  (All or None Bundle Compliance) 97.18 90 Q1
CY2014
Stroke (All or None Bundle Compliance) 83.33 90 Q1
CY2014
*30 Day Readmission Rate - AMI (Heart Attack) 0 0 June
2014
*30 Day Readmission Rate - Heart Failure 0 0 June
2014
*30 Day Readmission Rate - Pneumonia 6.70 0 June
2014
Median time of ED Arrival to ED Departure for IP Admit 276 205 June
2014
Median time of decision to ED departure for IP Admit 75 50 June
2014
Safety
Mortality Index 1.15 1.0 Q1
CY2014
Medication Events with Harm 0 0 June
2014
Efficiency
Patients leaving the Emergency Department without being seen 0.71 2.0 June
2014
Service / Patient Satisfaction: (Percentile Ranking)
"Willingness to recommend this Hospital?" 17.7% 90% Q1
CY2014
Learning Organization
Completion of Communication In Healthcare: All Staff
295 256 June
2014
Completion of Quality Essentials: All Staff 359 256 June
2014
Scorecard item Current Target Period
Outcomes
Acute MI (Heart Attack) All-or-None Bundle 100 100 Q1
CY2014
Heart Failure All-or-None Bundle 96.30 100 Q1
CY2014
Pneumonia All-or-None Bundle 100 100 Q1
CY2014
SCIP All-or-None Bundle 100 100 Q1
CY2014
VTE  (All or None Bundle Compliance) 100 90 Q1
CY2014
Stroke (All or None Bundle Compliance) 83.33 90 Q1
CY2014
*30 Day Readmission Rate - AMI (Heart Attack) 0 0 June
2014
*30 Day Readmission Rate - Heart Failure 16.70 0 June
2014
*30 Day Readmission Rate - Pneumonia 18.20 0 June
2014
Median time of ED Arrival to ED Departure for IP Admit 279 205 June
2014
Median time of decision to ED departure for IP Admit 52 50 June
2014
Safety
Mortality Index 1.40 1.0 Q1
CY2014
Medication Events with Harm 0 0 June
2014
Efficiency
Patients leaving the Emergency Department without being seen 2.66 2.0 June
2014
Service / Patient Satisfaction: (Percentile Ranking)
"Willingness to recommend this Hospital?" 1.4% 90% Q1
CY2014
Learning Organization
Completion of Communication In Healthcare: All Staff 330 242 June
2014
Completion of Quality Essentials: All Staff 342 242 June
2014
Scorecard item Current Target Period
Outcomes
Acute MI (Heart Attack) All-or-None Bundle na 100 Q1
CY2014
Heart Failure All-or-None Bundle 90.00 100 Q1
CY2014
Pneumonia All-or-None Bundle 100 100 Q1
CY2014
SCIP All-or-None Bundle 91.67 100 Q1
CY2014
VTE  (All or None Bundle Compliance) 100 90 Q1
CY2014
Stroke (All or None Bundle Compliance) 100 90 Q1
CY2014
*30 Day Readmission Rate - AMI (Heart Attack) 0 0 June
2014
*30 Day Readmission Rate - Heart Failure 11.10 0 June
2014
*30 Day Readmission Rate - Pneumonia 0 0 June
2014
Median time of ED Arrival to ED Departure for IP Admit 278 205 June
2014
Median time of decision to ED departure for IP Admit 61 50 June
2014
Safety
Mortality Index 2.23 1.0 Q1
CY2014
Medication Events with Harm 3.17 0 June
2014
Efficiency
Patients leaving the Emergency Department without being seen 1.60 2.0 June
2014
Service / Patient Satisfaction: (Percentile Ranking)
"Willingness to recommend this Hospital?" 56.2% 90% Q1
CY2014
Learning Organization
Completion of Communication In Healthcare: All Staff
449 364 June
2014
Completion of Quality Essentials: All Staff 422 364 June
2014

* Readmission Rate Targets are set based upon hospital bed size

Last Updated 08/01/2014