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Alegent Health Composite Scoring
Alegent Health is among a nationwide group of hospitals participating in
the Hospital Quality Alliance, a quality assessment program managed by
The Centers for Medicare and Medicaid Services (CMS). CMS is a Federal
agency within the U.S. Department of Health and Human Services.
Participating hospitals agree to publicly report
quality-of-care data on CMS�s Hospital Compare Web site. Hospitals
are presently required to submit data on 25 indicators that focus
on clinical processes. Several additional clinical process indicators
have been defined by CMS, but are not yet required for public reporting. However,
as part of Alegent Health�s pledge to provide the highest quality
of care, we are voluntarily reporting these five indicators on Alegent.com.
Out of the 30 reported indicators, 21 show how often
hospitals provide recommended care known to get the best results for most
patients being treated for heart attack (AMI), heart failure (HF) and
pneumonia (PN).
Nine indicators show how often hospitals provide
care that is known to reduce complications in surgical patients (SCIP).
Alegent Health has developed a Composite Scoring� formula
to report the quality of the overall care delivered for these important
clinical conditions and their indicators. These composite scores are reported
on AlegentHealth.com.
Our methodology for
calculating composite scores uses the verified data we report to CMS on 30
quality indicators for heart attack, heart failure, pneumonia, and
surgical care. The success rate for each indicator is as a
percentage. View the Alegent
Health Composite Score chart
This percentage is calculated as the number of patients
who actually received a particular treatment (numerator) divided by the
number of patients who should have received a particular treatment (denominator).
To calculate a composite score for each clinical area, the sum of the
numerators for each measure included in the clinical area is divided by
the sum of the denominators.
There are treatments for
heart attack (AMI), heart failure (HF), pneumonia (PN) and surgery (SCIP)
that are known to get the best results for most adult patients. Most
hospitals now track their delivery of these treatments as quality
indicators. A hospital�s quality indicator measurement reflects how often
they provide the treatments known to get the best results. The indicators
are explained in greater detail in our interactive quality tool
.
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Heart Attack (AMI)
- Angiotensin Converting Enzyme Inhibitor (ACEI) for Left Ventricular
Systolic Dysfunction (LVSD)
- Adult Smoking Cessation
- Aspirin at Arrival
- Aspirin at Discharge
- Beta Blocker at Arrival
- Beta Blocker at Discharge
- Percutaneous Transluminal Coronary Angioplasty (PTCA) within
120 Minutes
- Thrombolytic Medication within 30 Minutes
Heart Failure (HF)
- ACEI for LVSD
- Adult Smoking Cessation
- Left Ventricular Function (LVF) Assessment
- Discharge Instructions
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Pneumonia (PN)
- Adult Smoking Cessation
- Blood Culture before First Antibiotic
- First Antibiotic (ABX) within 4 Hours
- Oxygenation Assessment
- Pneumococcal Vacination
- Use of Recommended Antibiotics (ICU)
- Use of Recommended Antibiotics (Non-ICU)
- Pneumonia Blood Culture within 24 hours
- Influenza Vaccination
- Antibiotics discontinued within 24/48 hours
The Surgical Care Improvement Project (SCIP)
- Antibiotics One Hour Prior to procedure
- Selection from Recommended Antibiotics
- Post Operative Serum Glucose
- Appropriate Pre-operative Hair Removal
- Postoperative Normothermia
- Periop Beta Blocker
- SCIP VTE Prophylaxis Given
- SCIP VTE Prophylaxis Ordered
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