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.

Mission
Hospital
Angel
Medical Center
Blue Ridge
Regional Hospital
McDowell
Hospital
Transylvania
Regional Hospital

Scorecard item	Current	Target	Period
Outcomes
Acute MI (Heart Attack) All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
Heart Failure All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	97.54	100	Q3 CY2012
Pneumonia All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
SCIP All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	97.43	100	Q3 CY2012
*30 Day Readmission Rate - AMI (Heart Attack) Details X Inpatient stays for any reason that occurs within 30 days of a previous discharge of AMI ÷ all Patients with an inpatient stay of AMI. Excluding readmissions for rehab, psych care, observation or hospice.	5.22	8.40	Dec 2012
*30 Day Readmission Rate - Heart Failure Details X Inpatient stays for any reason that occurs within 30 days of a previous discharge of Heart Failure ÷ all Patients with an inpatient stay of Heart Failure. Excluding readmissions for rehab, psych care, observation or hospice.	20.00	17.37	Dec 2012
*30 Day Readmission Rate - Pneumonia Details X Inpatient stays for any reason that occurs within 30 days of a previous discharge of Pneumonia ÷ all Patients with an inpatient stay of Pneumonia. Excluding readmissions for rehab, psych care, observation or hospice.	8.73	12.59	Dec 2012
VTE (All or None Bundle Compliance)	91.17	99	Sept 2012
Stroke (All or None Bundle Compliance)	75%	95	Dec 2012
Median time of ED Arrival to ED Departure for IP Admit	329	286	Jan 2013
Median time of decision to ED departure for IP Admit	137	104	Jan 2013
Safety
Mortality Index Details X Observed rate of inpatient deaths / risk-adjusted expected rate	0.69	1.0	Q3 CY2012
SSI – COLO Surgeries	0	5.32	Jan 2013
Patient Safety Events Completed within 30 days	65%		Dec 2012
Medication Events with Harm Details X Category E-I Medication Events divided by 1,000,000 doses dispensed for the time period (12 month rolling average)	5.41	1.75	Jan 2013
Efficiency
Patients leaving the Emergency Department without being seen Details X Patients who left the ED without being evaluated - Patients who leave against medical advice (AMA) divided by all patients who presented to the ED	2.35	2.20	Jan 2013
Service / Patient Satisfaction: (Percentile Ranking)
"Willingness to recommend this Hospital?" Details X Percentile ranking within the PRC database based on % of "excellent" responses (5 out of 5 score)	86.60%	90%	Q4 CY2012
"Overall Quality of Care" Details X Percentile ranking within the PRC database based on % of "excellent" responses (5 out of 5 score)	89.20%		Q4 CY2012
Learning Organization
Completion of Communication In Healthcare: Annualized Target X Percentage of front line staff completing the Quality Essentials course	662	3520	Jan 2013
Completion of Quality Essentials: All Staff	14.5%	60%	Jan 2013

Scorecard item	Current	Target	Period
Outcomes
Acute MI (Heart Attack) All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
Heart Failure All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
Pneumonia All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
SCIP All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
*30 Day Readmission Rate - AMI (Heart Attack) Details X Inpatient stays for any reason that occurs within 30 days of a previous discharge of AMI ÷ all Patients with an inpatient stay of AMI. Excluding readmissions for rehab, psych care, observation or hospice.	0	0.85	Dec 2012
*30 Day Readmission Rate - Heart Failure Details X Inpatient stays for any reason that occurs within 30 days of a previous discharge of Heart Failure ÷ all Patients with an inpatient stay of Heart Failure. Excluding readmissions for rehab, psych care, observation or hospice.	40.00	8.77	Dec 2012
*30 Day Readmission Rate - Pneumonia Details X Inpatient stays for any reason that occurs within 30 days of a previous discharge of Pneumonia ÷ all Patients with an inpatient stay of Pneumonia. Excluding readmissions for rehab, psych care, observation or hospice.	9	5.88	Dec 2012
VTE (All or None Bundle Compliance)	97	99	Q3 2012
Stroke (All or None Bundle Compliance)	100	95	Q3 2012
Median time of ED Arrival to ED Departure for IP Admit	241	238	Jan 2013
Median time of decision to ED departure for IP Admit	100	70	Jan 2013
Safety
Mortality Index Details X Observed rate of inpatient deaths / risk-adjusted expected rate	2.98	1.0	Q3 CY2012
SSI – COLO Surgeries	0	5.74	Jan 2012
Patient Safety Events Completed within 30 days	100%		Dec 2012
Medication Events with Harm Details X Category E-I Medication Events divided by 1,000,000 doses dispensed for the time period (12 month rolling average)	0	0	Jan 2013
Efficiency
Patients leaving the Emergency Department without being seen Details X Patients who left the ED without being evaluated - Patients who leave against medical advice (AMA) divided by all patients who presented to the ED	0	2.20	Jan 2013
Service / Patient Satisfaction: (Percentile Ranking)
"Willingness to recommend this Hospital?" Details X Percentile ranking within the PRC database based on % of "excellent" responses (5 out of 5 score)	62.30%	90%	Q4 CY2012
"Overall Quality of Care" Details X Percentile ranking within the PRC database based on % of "excellent" responses (5 out of 5 score)	60.90%		Q4 CY2012
Learning Organization
Completion of Communication In Healthcare: Annualized Target X Percentage of leaders completing the Quality Essentials course	22	316	Jan 2013
Completion of Quality Essentials: All Staff X Percentage of front line staff completing the Quality Essentials course	78.7%	60%	Jan 2013

Scorecard item	Current	Target	Period
Outcomes
Acute MI (Heart Attack) All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
Heart Failure All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
Pneumonia All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
SCIP All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
*30 Day Readmission Rate - AMI (Heart Attack) Details X Inpatient stays for any reason that occurs within 30 days of a previous discharge of AMI ÷ all Patients with an inpatient stay of AMI. Excluding readmissions for rehab, psych care, observation or hospice.	0	0.85	Dec 2012
*30 Day Readmission Rate - Heart Failure Details X Inpatient stays for any reason that occurs within 30 days of a previous discharge of Heart Failure ÷ all Patients with an inpatient stay of Heart Failure. Excluding readmissions for rehab, psych care, observation or hospice.	0	8.77	Dec 2012
*30 Day Readmission Rate - Pneumonia Details X Inpatient stays for any reason that occurs within 30 days of a previous discharge of Pneumonia ÷ all Patients with an inpatient stay of Pneumonia. Excluding readmissions for rehab, psych care, observation or hospice.	5.00	5.88	Dec 2012
VTE (All or None Bundle Compliance)	96.88	99	Q3 2012
Stroke (All or None Bundle Compliance)	20	95	Q3 2012
Median time of ED Arrival to ED Departure for IP Admit	260	238	Jan 2013
Median time of decision to ED departure for IP Admit	67	70	Jan 2013
Safety
Mortality Index Details X Observed rate of inpatient deaths / risk-adjusted expected rate	7.25	1.0	Q3 CY2012
SSI – COLO Surgeries	0	6.87	Jan 2013
Patient Safety Events Completed within 30 days	13%		Dec 2012
Medication Events with Harm Details X Category E-I Medication Events divided by 1,000,000 doses dispensed for the time period (12 month rolling average)	0	0.29	Jan 2013
Efficiency
Patients leaving the Emergency Department without being seen Details X Patients who left the ED without being evaluated - Patients who leave against medical advice (AMA) divided by all patients who presented to the ED	2.65	2.20	Jan 2013
Service / Patient Satisfaction: (Percentile Ranking)
"Willingness to recommend this Hospital?" Details X Percentile ranking within the PRC database based on % of "excellent" responses (5 out of 5 score)	36.40%	90%	Q4 CY2012
"Overall Quality of Care" Details X Percentile ranking within the PRC database based on % of "excellent" responses (5 out of 5 score)	17.00%		Q4 CY2012
Learning Organization
Completion of Communication In Healthcare: Annualized Target X Percentage of leaders completing the Quality Essentials course	0	312	Jan 2013
Completion of Quality Essentials: All Staff X Percentage of front line staff completing the Quality Essentials course	44.0%	60%	Jan 2013

Scorecard item	Current	Target	Period
Outcomes
Acute MI (Heart Attack) All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
Heart Failure All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
Pneumonia All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
SCIP All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	81.00	100	Q3 CY2012
*30 Day Readmission Rate - AMI (Heart Attack) Details X Inpatient stays for any reason that occurs within 30 days of a previous discharge of AMI ÷ all Patients with an inpatient stay of AMI. Excluding readmissions for rehab, psych care, observation or hospice.	0	0.85	Dec 2012
*30 Day Readmission Rate - Heart Failure Details X Inpatient stays for any reason that occurs within 30 days of a previous discharge of Heart Failure ÷ all Patients with an inpatient stay of Heart Failure. Excluding readmissions for rehab, psych care, observation or hospice.	28.57	8.77	Dec 2012
*30 Day Readmission Rate - Pneumonia Details X Inpatient stays for any reason that occurs within 30 days of a previous discharge of Pneumonia ÷ all Patients with an inpatient stay of Pneumonia. Excluding readmissions for rehab, psych care, observation or hospice.	9.52	5.88	Dec 2012
VTE (All or None Bundle Compliance)	100	99	Q3 2012
Stroke (All or None Bundle Compliance)	100	95	Q3 2012
Median time of ED Arrival to ED Departure for IP Admit	282.21	238	Q3 2012
Median time of decision to ED departure for IP Admit	75.34	70	Q3 2012
Safety
Mortality Index Details X Observed rate of inpatient deaths / risk-adjusted expected rate	1.03	1.0	Q3 CY2012
SSI – COLO Surgeries	0	5.49	Jan 2013
Patient Safety Events Completed within 30 days	100%	0	Dec 2012
Medication Events with Harm Details X Category E-I Medication Events divided by 1,000,000 doses dispensed for the time period (12 month rolling average)	8.82	0	Jan 2013
Efficiency
Patients leaving the Emergency Department without being seen Details X Patients who left the ED without being evaluated - Patients who leave against medical advice (AMA) divided by all patients who presented to the ED	2.99	2.20	Jan 2013
Service / Patient Satisfaction: (Percentile Ranking)
"Willingness to recommend this Hospital?" Details X Percentile ranking within the PRC database based on % of "excellent" responses (5 out of 5 score)	19.50%	90%	Q4 CY2012
"Overall Quality of Care" Details X Percentile ranking within the PRC database based on % of "excellent" responses (5 out of 5 score)	28.2%		Q4 CY2012
Learning Organization
Completion of Communication In Healthcare: Annualized Target X Percentage of leaders completing the Quality Essentials course	4	272	Jan 2013
Completion of Quality Essentials: All Staff X Percentage of front line staff completing the Quality Essentials course	46.2%	60%	Jan 2013

Scorecard item	Current	Target	Period
Outcomes
Acute MI (Heart Attack) All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
Heart Failure All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
Pneumonia All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
SCIP All-or-None Bundle Details X Patients that received all processes of care for which the patient was eligible ÷ All patients that qualified for one or more measures in the set	100	100	Q3 CY2012
*30 Day Readmission Rate - AMI (Heart Attack) Details X Inpatient stays for any reason that occurs within 30 days of a previous discharge of AMI ÷ all Patients with an inpatient stay of AMI. Excluding readmissions for rehab, psych care, observation or hospice.	0	0.85	Dec 2012
*30 Day Readmission Rate - Heart Failure Details X Inpatient stays for any reason that occurs within 30 days of a previous discharge of Heart Failure ÷ all Patients with an inpatient stay of Heart Failure. Excluding readmissions for rehab, psych care, observation or hospice.	0	8.77	Dec 2012
*30 Day Readmission Rate - Pneumonia Details X Inpatient stays for any reason that occurs within 30 days of a previous discharge of Pneumonia ÷ all Patients with an inpatient stay of Pneumonia. Excluding readmissions for rehab, psych care, observation or hospice.	0	5.88	Dec 2012
VTE (All or None Bundle Compliance)	100	99	Oct 2012
Stroke (All or None Bundle Compliance)	100	95	Oct 2012
Median time of ED Arrival to ED Departure for IP Admit	230.71	238	Oct 2012
Median time of decision to ED departure for IP Admit	79.97	70	Oct 2012
Safety
Mortality Index Details X Observed rate of inpatient deaths / risk-adjusted expected rate	1.65	1.0	Q3 CY2012
SSI – COLO Surgeries	0	5.56	Jan 2013
Patient Safety Events Completed within 30 days	n/a	0	Dec 2012
Medication Events with Harm Details X Category E-I Medication Events divided by 1,000,000 doses dispensed for the time period (12 month rolling average)	1.93	1.89	Jan 2013
Efficiency
Patients leaving the Emergency Department without being seen Details X Patients who left the ED without being evaluated - Patients who leave against medical advice (AMA) divided by all patients who presented to the ED	1.36	2.20	Jan 2013
Service / Patient Satisfaction: (Percentile Ranking)
"Willingness to recommend this Hospital?" Details X Percentile ranking within the PRC database based on % of "excellent" responses (5 out of 5 score)	75.20%	90%	Q4 CY2012
"Overall Quality of Care" Details X Percentile ranking within the PRC database based on % of "excellent" responses (5 out of 5 score)	77.30%		Q4 CY2012
Learning Organization
Completion of Communication In Healthcare: Annualized Target X Percentage of leaders completing the Quality Essentials course	17	408	Jan 2013
Completion of Quality Essentials: All Staff X Percentage of front line staff completing the Quality Essentials course	14%	60%	Jan 2013

* Readmission Rate Targets are set based upon hospital bed size

Last Updated 03/26/2013

Quality Scorecards

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