Measures for Pneumonia Diagnoses

This table shows our percentage of compliance with every patient care standard being measured. A score of 91% means we were compliant with patient care best practices 91% of the time.

This table illustrates measures for past fiscal years and for each quarter of the current fiscal year. It shows our percentage of compliance with patient care best practices for adults diagnosed with pneummonia.

Core Measures (Reported for recently available quarter: FY09 Q2 )		TRENDED QUALITY DATA
Jewish Hospital Pneumonia Care Quality Measures		FY06 (Jul 05 - Jun 06)	FY07 (Jul 06 - Jun 07)	FY08** (Jul 07 - Mar 08)	FY09** (Jul 08 - Dec 08)	FY08 Q3 (Jan 08 - Mar 08)	FY08 Q4 (Apr 08 - Jun 08)	FY09 Q1 (Jul 08 - Sep 08)	FY09 Q2 (Oct 08 - Dec 08)	Benchmark* (Jul 07- Jun 08 )
	CMS Validated+	√	√	√		√	√	√
PN-1	Oxygenation Assessment (%)	99%	100%	100%		100%	100%	100%	100%	100%
PN-2	Pneumococcal Vaccination (%)	63%	91%	92%		93%	100%	97%	91%	87%
PN-3b	Blood Cultures Performed Before First Antibiotic Received (%)	80%	95%	94%		93%	97%	97%	98%	92%
PN-4	Adult Smoking Cessation Advice/Counseling (%)	72%	95%	100%		100%	100%	100%	92%	92%
PN-5c	Antibiotic w/in 6 hours of Arrival (%)	n/a	n/a	93%		88%	93%	94%	91%	94%
	Perfect Score ** Patients who had all elements of care done correctly for the treatment of Pneumonia.	43%	77%	78%	85%	81%	89%	90%	80%
	Pneumonia Composite Score The "Composite Score Approach" = the sum of the numerators for each measure divided by the sum of the denominators for each measure times 100..	84%	94%	94%	96%	93%	98%	97%	95%

+ The Centers for Medicare and Medicaid (CMS) audits a sample of patient records to make sure that reported numbers are accurate. The CMS process lags several months behind and so our most recent results have not been validated by CMS yet. Our validation scores are consistently good and we anticipate that the results shown accurately reflect performance for that interval.
* Benchmark from Centers for Medicare and Medicaid - HHS Hospital Compare website, most current benchmark for SW Ohio.
*** Effective October, 2007, the Pneumonia Composite Score inludes only Antibotic within 6 hours rather than 4 and 8 hours (per CMS changes). Scores were re-calculated to reflect this change.

FY09 Q2		CURRENT QUALITY SCORES FOR THE HEALTH ALLIANCE
All Health Alliance Pneumonia Care Quality Measures		The University Hospital	The Jewish Hospital	Fort Hamilton Hospital	Benchmark* (Jul 07- Jun 08)
PN-1	Oxygenation Assessment (%)	100%	100%	100%	100%
PN-2	Pneumococcal Vaccination (%)	60%	91%	95%	87%
PN-3b	Blood Cultures Performed Before First Antibiotic Received (%)	97%	98%	99%	92%
PN-4	Adult Smoking Cessation Advice/Counseling (%)	100%	92%	100%	92%
PN-5c	Antibiotic w/in 6 hours of Arrival (%)	97%	91%	94%	94%
	Perfect Score ** Patients who had all elements of care done correctly for the treatment of Pneumonia.	71%	80%	88%
	Pneumonia Composite Score ** The "Composite Score Approach" = the sum of the numerators for each measure divided by the sum of the denominators for each measure times 100.	95%	95%	97%

* Benchmark from Centers for Medicare and Medicaid - HHS Hospital Compare website, most current benchmark for Ohio.

** Includes Christ and St. Luke Hospitals through June, 2007

Oxygenation assessment
Having enough oxygen in your blood is important to your health.

This measure shows the percent of pneumonia patients who receive an oxygenation assessment, arterial blood gas (ABG), or pulse oximetry within 24 hours of hospital arrival.

Pneumococcal vaccination
A pneumonia (pneumococcal) shot can help prevent pneumonia in the future, even for patients who have been hospitalized for pneumonia.

This measure shows the percent of pneumonia patients age 65 and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharged, if indicated.

Blood cultures performed before first antibiotic received
A blood culture tells what kind of medicine will work best to treat patients’ pneumonia.

This measure shows the percent of pneumonia patients whose blood culture specimen was collected prior to first hospital dose of antibiotics.

Adult smoking cessation advice/ counseling
Smoking is linked to pneumonia. Quitting may help prevent getting pneumonia again.

This measure shows the percent of pneumonia patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during a hospital stay.

Antibiotic w/in 8 hours of arrival
Timely use of antibiotics can improve the treatment of pneumonia caused by bacteria.

This measure shows the percent of pneumonia patients that receive within 8 hours after arrival at the hospital.

Antiobiotic w/in 4 hours of arrival
Timely use of antibiotics can improve the treatment of pneumonia caused by bacteria.

This measure shows the percent of pneumonia patients that receive within 4 hours after arrival at the hospital.

Using the tables as a guide for these three areas, you can see our progress year to year and quarter to quarter.

If you have any questions about the information provided on this site, please contact Health Alliance Quality Management Services at QualityManagementServices@healthall.com.