Outcomes: Our Numbers Tell the Story
Core Measures Show Quality: January 2012 Reporting
Data on Beaufort Memorial's performance as well as other hospitals nationwide are posted on the Center for Medicare & Medicaid Services (CMS) website at www.hospitalcompare.gov. However, that data is very outdated by the time it is posted. The data below is more current for Beaufort Memorial. For more information on these reports please visit:
Updated: 4/10/2012
South Carolina’s Hospitals Must Share Certain Infection Data with YouIn 2006, state lawmakers passed the Hospital Infections Disclosure Act (HIDA). This law requires hospitals to report certain infection rates to the S.C. Department of Health and Environmental Control (DHEC) and the public.
Twice a year, hospitals are required to report infections that patients developed while being treated in the hospital. Hospitals are not required to report infections that patients had when they were admitted.
HIDA Goals:
- Promote better infection prevention practices in South Carolina
- Give S.C. citizens and public health officials a way to measure the state’s progress in reducing, and perhaps one day eliminating, hospital acquired infections.
How Infections are Spread in Hospitals
- Routine care (hands, equipment)
- Surgery
- Ventilators, catheters, central lines and other medical devices
- Overuse of antibiotics
| Heart Attack or Chest Pain Process of Care Measures | |||||
| Measure | Percentage
Compliance with Standard of Care |
||||
National Average
|
South Carolina Average | Beaufort Memorial Hospital Average | Data Collected from | Data Collected To |
|
| Average number of minutes before outpatients with chest pain or possible heart attack who needed specialized care were transferred to
another hospital (a lower number of minutes is better) |
60 minutes |
59 minutes |
N/A minutes |
4/1/2010 |
3/31/2011 |
| Average number of minutes before outpatients with chest pain or possible heart attack got an ECG (a lower number of minutes is better) | 8 minutes |
7 minutes |
24 minutes of 25 patients |
4/1/2010 |
3/31/2011 |
| Outpatients with chest pain or possible heart attack who got drugs to break up blood clots within 30 minutes of arrival (higher numbers are better) | 57% |
61% |
100% of 2 patients |
4/1/2010 |
3/31/2011 |
| Outpatients with chest pain or possible heart attack who got aspirin
within 24 hours of arrival (higher numbers are better) |
96% |
96% |
96% of 23 patients |
4/1/2010 |
3/31/2011 |
| Heart Attack Patients Given Aspirin at Arrival |
99% |
99% |
97% of 38 patients |
4/1/2010 |
3/31/2011 |
| Heart Attack Patients Given Aspirin at Discharge | 99% | 99% | 97% of 29 patients |
4/1/2010 | 3/31/2011 |
| Heart Attack Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) | 97% | 97% | 100% of 7 patients |
4/1/2010 | 3/31/2011 |
| Heart Attack Patients Given Smoking Cessation Advice/Counseling | 100% | 100% | 100% of 8 patients |
4/1/2010 | 3/31/2011 |
| Heart Attack Patients Given Beta Blocker at Discharge | 99% | 99% | 100% of 31 patients |
4/1/2010 | 3/31/2011 |
| Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes Of Arrival | 58% | 67% | N/A | 4/1/2010 | 3/31/2011 |
| Heart Attack Patients Given PCI Within 90 Minutes Of Arrival | 92% | 95% | N/A | 4/1/2010 | 3/31/2011 |
| Heart Attack Patients Given a Prescription for a Statin at Discharge | 97% | 97% | 73% of 11 patients |
4/1/2010 | 3/31/2011 |
| Heart Failure Process of Care Measures | |||||
| Measure | Percentage
Compliance with Standard of Care |
||||
National Average |
South Carolina Average | Beaufort Memorial Hospital Average | Data Collected from | Data Collected To |
|
| Heart
Failure Patients Given Discharge Instructions |
90% |
90% |
100% of 282 patients |
4/1/2010 |
3/31/2011 |
| Heart
Failure Patients Given Assessment of Left Ventricular
Function (LVF) |
98% |
99% |
100% of 301 patients |
4/1/2010 |
3/31/2011 |
| Heart
Failure Patients Given ACE Inhibitor or ARB for Left
Ventricular Systolic Dysfunction (LVSD) |
95% |
96% |
97% of 122 patients |
4/1/2010 |
3/31/2011 |
| Heart
Failure Patients Given Smoking Cessation Advice/Counseling |
99% |
100% |
100% of 74 patients |
4/1/2010 |
3/31/2011 |
| Pneumonia Process of Care Measures | |||||
| Measure | Percentage
Compliance with Standard of Care |
||||
National Average |
South Carolina Average | Beaufort Memorial Hospital Average | Data Collected from | Data Collected To |
Pneumococcal
Vaccination |
94% |
96% |
92% of 60 patients |
4/1/2010 |
3/31/2011 |
| Blood
Culture Performed Prior to First Antibiotic Received
in Hospital |
96% |
97%
|
94% of 83 patients |
4/1/2010 |
3/31/2011 |
| Adult
Smoking Cessation Advice/Counseling |
98% |
99% |
100% of 32 patients |
4/1/2010 |
3/31/2011 |
| Initial
Antibiotic(s) within 6 Hours of Arrival |
96% |
96% |
78% of 9 patients |
4/1/2010 |
3/31/2011 |
| Pneumonia Patients Given the Most Appropriate Initial Antibiotic |
94% |
94% |
88% of 52 patients |
4/1/2010 |
3/31/2011 |
| Influenza
Vaccination |
93% |
95% |
100% of 60 patients |
4/1/2010 |
3/31/2011 |
| Surgical Care Improvement Project (SCIP): Core Measure Trends | |||||
| Measure | Percentage
Compliance with Standard of Care |
||||
National Average |
South Carolina Average | Beaufort Memorial Hospital Average | Data Collected from | Data Collected To |
|
| Outpatients having surgery who got an antibiotic at the right time -
within one hour before surgery (higher numbers are better) |
95% |
95% |
92% of 103 patients |
4/1/2010 |
3/31/2011 |
| Outpatients having surgery who got the right kind of antibiotic
numbers are better) |
95% |
96%
|
89% of 100 patients |
4/1/2010 |
3/31/2011 |
| Surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on the beta blockers during the period just before and after their surgery | 95% |
96% |
92% of 134 patients |
4/1/2010 |
3/31/2011 |
| Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection | 97% |
98% |
96% of 528 patients |
4/1/2010 |
3/31/2011 |
| Surgery patients who were given the right kind of antibiotic to help prevent infection | 98% |
98% |
96% of 534 patients |
4/1/2010 |
3/31/2011 |
| Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery) | 96% |
96% |
95% of 495 patients |
4/1/2010 |
3/31/2011 |
| Heart surgery patients whose blood sugar (blood glucose) is kept under good control in the days right after surgery | 94% |
96% |
N/A |
4/1/2010 |
3/31/2011 |
| Surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electric clippers or hair removal cream - not a razor) | 100% |
100% |
100% of 704 patients |
4/1/2010 |
3/31/2011 |
| Surgery patients whose urinary catheters were removed on the first or second day after surgery. | 92% |
94% |
96% of 452 patients |
4/1/2010 |
3/31/2011 |
| Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery. | 99% |
100% |
100% of 744 patients |
4/1/2010 |
3/31/2011 |
| Surgery patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries | 95% |
96% |
93% of 367 patients |
4/1/2010 |
3/31/2011 |
| Patients who got treatment at the right time (within 24 hours before or after their surgery) to help prevent blood clots after certain types of surgery | 94% |
95% |
92% of 367 patients |
4/1/2010 |
3/31/2011 |
For comparative information on AMI, heart failure and pneumonia, and to learn more about the Hospital Compare program, go to www.HospitalCompare.hhs.gov.
“Our
mission is to provide superior healthcare services and to
improve the health of our community and we believe that disclosing
useful information to patients is one of the many ways we
fulfill our mission.”
—Pat Foulger, BMH Vice President
for Quality Services
