Measures for Surgical Procedures

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 having surgical procedures.

Core Measures (Reported for most recently available quarter: FY09 Q2 )		TRENDED QUALITY DATA (Most recent 3 years)			(Most recent 4 quarters)
Jewish Hospital Surgical Care Improvement Quality Measures		FY07 (Jul 06 - Jun 07)	FY08** (Jul 07 - Mar 08)	YTD FY09** (Jul 08 - Jun 09)	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 Data+		√	√	√	√	√	√
Inf-1a	Antibiotic within 1 hour of incision (%)	86%	84%	95%	84%	96%	90%	92%	87%
Inf-2a	Antibiotic selection (%)	95%	94%	96%	96%	96%	99%	98%	93%
Inf-3a	Antibiotic discontinued within 24 hours (%)	76%	91%	84%	93%	94%	93%	99%	82%
VTE-1	VTE prophylaxis ordered (%)	75%	85%	99%	95%	96%	98%	94%	86%
VTE-2	VTE prophylaxis timing (%)	72%	82%	95%	92%	94%	97%	94%	83%
	SCIP 1-2-3 Perfect Score ** Patients who had all elements of care done correctly for the treatment of Surgical Care.	66%	73%	90%	77%	92%	90%	91%
	Surgical Care Improvement 1-2-3 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.	86%	90%	95%	91%	95%	94%	97%

+ 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.

FY09 Q2		CURRENT QUALITY SCORES FOR THE HEALTH ALLIANCE
All Health Alliance Surgical Care Improvement Quality Measures		University Hospital	Jewish Hospital	Fort Hamilton Hospital	Benchmark* (Jul 07 - Jun 08)
Inf-1a	Antibiotic within 1 hour of incision (%)	96%	92%	96%	88%
Inf-2a	Antibiotic selection (%)	98%	98%	86%	95%
Inf-3a	Antibiotic discontinued within 24 hours (%)	79%	99%	91%	87%
VTE-1	VTE prophylaxis ordered (%)	96%	94%	87%	88%
VTE-2	VTE prophylaxis timing (%)	98%	94%	82%	86%
	SCIP 1-2-3 Perfect Score ** Patients who had all elements of care done correctly for the treatment of Surgical Care.	83%	91%	79%
	Surgical Care Improvements 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.	96%	97%	88%

* 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

Using the tables as a guide for these four 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.