Congestive Heart Failure (HF)

SRMC Current Quarter

SRMC Change Qtr to Qtr

+

JCAHO Ntl Average

Discharge Instructions

79.31%

↑2%

+

65%

Assessment of LVF

95%

↑1%

+

92%

ACE or ARB for LVSD-HF

80%

↑8%

-

85%

Adult Smoking Cessation-HF

100%

↑6%

+

89%

Pneumonia (PN)

SRMC Current Quarter

SRMC Change Qtr to Qtr

√

JCAHO Ntl Average

Oxygenation Assessment

100%

NC

√

100%

Pneumococcal Vaccination

53.6%

↑4%

-

71%

Blood Cultures w/i 24 hours of hosp arrival: pts transferred/admitted ICU

81.25%

↓8%

-

89%

Blood Culture before First Antibiotic-ED

87.8%

↓1%

-

90%

Adult Smoking Cessation-Pneumonia

95.24%

↑10%

+

86%

Antibiotic Within 4 hours after arrival

84.62%

↓3%

+

77%

Appropriate Initial Antibiotic Selection-ICU patient

44.4%

↑25

-

57%

Appropriate Initial Antibiotic Selection-Non ICU patient

100%

↑5%

+

87%

Acute Myocardial Infarction (AMI)

SRMC Current Quarter

SRMC Change Qtr to Qtr

+

JCAHO Ntl Average

Aspirin at Arrival

100%

NC

+

96%

Aspirin at Discharge

100%

↑12.5%

+

96%

ACE or ARB for LVSD-AMI

85.7%

↓12%

+

85%

Adult Smoking Cessation-AMI

100%

NC

+

95%

Beta Blocker at Discharge

95%

↑5%

√

96%

Beta Blocker at Arrival

95%

↓2%

√

93%

Thrombolytic Medication within 30 minutes of Arrival

N/A

N/A

N/A

39%

PCI Within 90 minutes of Arrival

100%

↑100%

+

72%

Surgical Care Improvement Project (SCIP)

SRMC Current Quarter

SRMC Change Qtr to Qtr

_

JCAHO Ntl Average

PreOp Antibiotic within 60 minutes (overall)

83.6%

↑13%

+

85%

Initial Antibiotic Selection

95%

↑3%

PostOp Antibiotic discontinued within 24 hours after surgery end (overall)

29.5%

↓4%

-

77%