Hospital Inpatient Quality Reporting Benchmarks and Trends
Hospital Inpatient Quality Reporting Benchmarks and Trends Third Quarter 2011 through Third Quarter 2012 Benchmarks for Hospital-Abstracted Acute Myocardial Infarction (AMI) Data - Third Quarter 2012 Using the ABC Technique* *The benchmarks reported here are unrelated to the 90th percentiles that are published on Hospital Compare for individual measures. Benchmark Rate (%) Numerator (Benchmark) Denominator (Benchmark) Number of Hospitals (Benchmark) National Rate (%) Numerator (National) Denominator (National) Number of Hospitals (National) AMI-1: Aspirin at Arrival 100.0 11,740 11,742 61 99.3 115,432 116,200 3,053 AMI-2: Aspirin Prescribed at Discharge 100.0 10,539 10,541 57 99.2 104,196 105,069 2,930 AMI-3: ACEI or ARB for LVSD 99.9 1,904 1,906 52 97.7 17,341 17,754 2,194 AMI-5: Beta-Blocker at Discharge 100.0 10,355 10,356 60 99.0 99,070 100,055 2,892 AMI-7a: Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival 100.0 17 17 5 66.5 105 158 105 AMI-8a: Primary PCI Received within 90 Minutes of Hospital Arrival 100.0 1,557 1,557 64 95.2 14,257 14,974 1,570 AMI-10: Statin Prescribed at Discharge 100.0 10,341 10,346 65 98.1 99,692 101,617 2,916 Performance Measure Name *Benchmark Rate(%) is calculated using the Top 10% Sample. *National Rate(%) is calculated using the 100% Eligible Sample. *ACEI = Angiotensin Converting Enzyme Inhibitor *ARB = Angiotensin Receptor Blocker *LVSD = Left Ventricular Systolic Dysfunction *PCI = Percutaneous Coronary Intervention *Selected references 1. Kiefe C I, Weissman N W, Allison J J, et al. Identifying achievable benchmarks of care: Concept and methodology. International Journal for Quality in Health Care 1998, vol 10 (5): 443-447. 2. Weissman N W, Allison J J, Kiefe C I, et al. Achievable benchmarks of care: the ABC's of benchmarking. Journal of Evaluation in Clinical Practice 1999, vol 5 (3): 269-281. 3. Allison J, Kiefe C I, Wessman N W. Can data-driven benchmarks be used to set goals of Healthy People 2010? American Journal of Public Health 1999, vol 89 (1): 61-65. 4. Allison J, Kiefe C I, Wessman N W, et al. Achievable benchmarks of care (ABC): User manual. Center for Outcome and Effectiveness Research and Education (COERE). University of Alabama at Birmingham. The benchmarks of care can be found on QualityNet at: https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228768205297 This material was prepared by Oklahoma Foundation for Medical Quality, Inc. (OFMQ), the Medicare Quality Improvement Organization for Oklahoma, under the Measures Development Special Studies contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SPOK01-1673-OK-0513 HIQR Benchmarks and Trends - 3Q2012 Date Completed: May 15, 2013 Page 1 of 13 Trends of Acute Myocardial Infarction (AMI) Performance Measures and Benchmarks from Third Quarter 2011 to Third Quarter 2012 *The benchmarks reported here are unrelated to the 90th percentiles that are published on Hospital Compare for individual measures. Performance Measure Name AMI-1: Aspirin at Arrival AMI-2: Aspirin Prescribed at Discharge Qtr 3 2011 Benchmark Rate (%) 100.0 Qtr 3 2011 National Rate (%) 99.2 Qtr 4 2011 Benchmark Rate (%) 100.0 Qtr 4 2011 National Rate (%) 99.2 Qtr 1 2012 Benchmark Rate (%) 100.0 Qtr 1 2012 National Rate (%) 99.2 Qtr 2 2012 Benchmark Rate (%) 100.0 Qtr 2 2012 National Rate (%) 99.3 Qtr 3 2012 Benchmark Rate (%) 100.0 Qtr 3 2012 National Rate (%) 99.3 100.0 99.0 100.0 99.1 100.0 99.1 100.0 99.1 100.0 99.2 AMI-3: ACEI or ARB for LVSD AMI-5: Beta-Blocker Prescribed at Discharge 99.9 97.3 99.9 97.7 100.0 97.6 99.9 97.5 99.9 97.7 100.0 98.9 100.0 98.9 100.0 98.9 100.0 99.0 100.0 99.0 AMI-7a: Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival 100.0 62.6 100.0 55.4 100.0 58.8 100.0 65.3 100.0 66.5 99.9 93.9 99.9 94.4 99.9 94.6 99.9 95.1 100.0 95.2 100.0 97.5 100.0 97.6 99.9 97.8 100.0 98.0 100.0 98.1 AMI-8a: Primary PCI Received within 90 Minutes of Hospital Arrival AMI-10: Statin Prescribed at Discharge The following graphs represent the information in the table above. The blue lines with diamond points (♦) represent the national rates and the dark red lines with square points (■) represent the benchmarks. AMI-1: Aspirin at Arrival AMI-2: Aspirin Prescribed at Discharge AMI-3: ACEI or ARB for LVSD 100.0 100.0 100.0 95.0 95.0 95.0 90.0 90.0 90.0 85.0 85.0 85.0 80.0 80.0 80.0 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 Qtr 3 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 AMI-8a: Primary PCI Received Within 90 Minutes of Hospital Arrival AMI-7a: Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival 100.0 90.0 80.0 70.0 60.0 50.0 Qtr 4 2011 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 100.0 95.0 90.0 90.0 85.0 85.0 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 95.0 90.0 85.0 80.0 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 AMI-10: Statin Prescribed at Discharge 95.0 Qtr 3 2011 100.0 Qtr 3 2011 100.0 80.0 AMI-5: Beta-blocker Prescribed at Discharge 80.0 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 *ACEI = Angiotensin Converting Enzyme Inhibitor *ARB = Angiotensin Receptor Blocker *LVSD = Left Ventricular Systolic Dysfunction *PCI = Percutaneous Coronary Intervention *Qtr = Quarter HIQR Benchmarks and Trends - 3Q2012 Date Completed: May 15, 2013 Page 2 of 13 Benchmarks for Hospital-Abstracted Heart Failure (HF) Data - Third Quarter 2012 Using the ABC Technique* *The benchmarks reported here are unrelated to the 90th percentiles that are published on Hospital Compare for individual measures. Benchmark Rate (%) Numerator (Benchmark) Denominator (Benchmark) Number of Hospitals (Benchmark) National Rate (%) Numerator (National) Denominator (National) Number of Hospitals (National) HF-1: Discharge Instructions 99.9 13,777 13,792 127 93.6 124,080 132,622 3,988 HF-2: Evaluation of LVS Function 100.0 16,869 16,869 80 98.8 162,893 164,875 4,094 HF-3: ACEI or ARB for LVSD 99.9 5,152 5,155 84 96.6 48,775 50,471 3,533 Performance Measure Name *Benchmark Rate(%) is calculated using the Top 10% Sample. *National Rate(%) is calculated using the 100% Eligible Sample. *ACEI = Angiotensin Converting Enzyme Inhibitor *ARB = Angiotensin Receptor Blocker *LVS = Left Ventricular Systolic *LVSD = Left Ventricular Systolic Dysfunction *Selected references 1. Kiefe C I, Weissman N W, Allison J J, et al. Identifying achievable benchmarks of care: Concept and methodology. International Journal for Quality in Health Care 1998, vol 10 (5): 443-447. 2. Weissman N W, Allison J J, Kiefe C I, et al. Achievable benchmarks of care: the ABC's of benchmarking. Journal of Evaluation in Clinical Practice 1999, vol 5 (3): 269281. 3. Allison J, Kiefe C I, Wessman N W. Can data-driven benchmarks be used to set goals of Healthy People 2010? American Journal of Public Health 1999, vol 89 (1): 6165. 4. Allison J, Kiefe C I, Wessman N W, et al. Achievable benchmarks of care (ABC): User manual. Center for Outcome and Effectiveness Research and Education (COERE). University of Alabama at Birmingham. The benchmarks of care can be found on QualityNet at: https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228768205297 This material was prepared by Oklahoma Foundation for Medical Quality, Inc. (OFMQ), the Medicare Quality Improvement Organization for Oklahoma, under the Measures Development Special Studies contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SPOK01-1673-OK-0513 HIQR Benchmarks and Trends - 3Q2012 Date Completed: May 15, 2013 Page 3 of 13 Trends of Heart Failure (HF) Performance Measures and Benchmarks from Third Quarter 2011 to Third Quarter 2012 *The benchmarks reported here are unrelated to the 90th percentiles that are published on Hospital Compare for individual measures. Qtr 3 2011 Benchmark Rate (%) Qtr 3 2011 National Rate (%) Qtr 4 2011 Benchmark Rate (%) Qtr 4 2011 National Rate (%) Qtr 1 2012 Benchmark Rate (%) Qtr 1 2012 National Rate (%) Qtr 2 2012 Benchmark Rate (%) Qtr 2 2012 National Rate (%) Qtr 3 2012 Benchmark Rate (%) Qtr 3 2012 National Rate (%) HF-1: Discharge Instructions 99.9 92.6 99.9 92.7 99.9 93.1 99.9 93.3 99.9 93.6 HF-2: Evaluation of LVS Function 100.0 98.6 100.0 98.7 100.0 98.7 100.0 98.7 100.0 98.8 HF-3: ACEI or ARB for LVSD 99.9 96.3 100.0 96.5 100.0 96.4 99.9 96.5 99.9 96.6 Performance Measure Name The following graphs represent the information in the table above. The blue lines with diamond points (♦) represent the national rates and the dark red lines with square points (■) represent the benchmarks. 100.0 HF-1: Discharge Instructions HF-3: ACEI or ARB for LVSD HF-2: Evaluation of LVS Function 100.0 100.0 95.0 95.0 95.0 90.0 90.0 90.0 85.0 85.0 85.0 80.0 80.0 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 80.0 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 *ACEI = Angiotensin Converting Enzyme Inhibitor *ARB = Angiotensin Receptor Blocker *LVSD = Left Ventricular Systolic *LVSD = Left Ventricular Systolic Dysfunction *Qtr = Quarter HIQR Benchmarks and Trends - 3Q2012 Date Completed: May 15, 2013 Page 4 of 13 Benchmarks for Hospital-Abstracted Pneumonia (PN) Data - Third Quarter 2012 Using the ABC Technique* *The benchmarks reported here are unrelated to the 90th percentiles that are published on Hospital Compare for individual measures. Performance Measure Name Benchmark Rate (%) Numerator (Benchmark) Denominator (Benchmark) Number of Hospitals (Benchmark) National Rate (%) Numerator (National) Denominator (National) Number of Hospitals (National) 100.0 2,443 2,444 76 97.8 23,026 23,546 3,012 99.9 11,134 11,145 121 97.5 107,264 109,960 3,981 99.8 6,750 6,761 149 95.0 63,008 66,299 4,083 PN-3a: Blood Cultures Performed Within 24 Hours to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival PN-3b: Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital PN-6: Initial Antibiotic Selection for CAP in Immunocompetent Patient *Benchmark Rate(%) is calculated using the Top 10% Sample. *National Rate(%) is calculated using the 100% Eligible Sample. *ICU = Intensive Care Unit *CAP = Community Acquired Pneumonia *Selected references 1. Kiefe C I, Weissman N W, Allison J J, et al. Identifying achievable benchmarks of care: Concept and methodology. International Journal for Quality in Health Care 1998, vol 10 (5): 443-447. 2. Weissman N W, Allison J J, Kiefe C I, et al. Achievable benchmarks of care: the ABC's of benchmarking. Journal of Evaluation in Clinical Practice 1999, vol 5 (3): 269-281. 3. Allison J, Kiefe C I, Wessman N W. Can data-driven benchmarks be used to set goals of Healthy People 2010? American Journal of Public Health 1999, vol 89 (1): 61-65. 4. Allison J, Kiefe C I, Wessman N W, et al. Achievable benchmarks of care (ABC): User manual. Center for Outcome and Effectiveness Research and Education (COERE). University of Alabama at Birmingham. The benchmarks of care can be found on QualityNet at: https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228768205297 This material was prepared by Oklahoma Foundation for Medical Quality, Inc. (OFMQ), the Medicare Quality Improvement Organization for Oklahoma, under the Measures Development Special Studies contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SPOK01-1673-OK-0513 HIQR Benchmarks and Trends - 3Q2012 Date Completed: May 15, 2013 Page 5 of 13 Trends of Pneumonia (PN) Performance Measures and Benchmarks from Third Quarter 2011 to Third Quarter 2012 *The benchmarks reported here are unrelated to the 90th percentiles that are published on Hospital Compare for individual measures. Qtr 3 2011 Benchmark Rate (%) Qtr 3 2011 National Rate (%) Qtr 4 2011 Benchmark Rate (%) Qtr 4 2011 National Rate (%) Qtr 1 2012 Benchmark Rate (%) Qtr 1 2012 National Rate (%) Qtr 2 2012 Benchmark Rate (%) Qtr 2 2012 National Rate (%) Qtr 3 2012 Benchmark Rate (%) Qtr 3 2012 National Rate (%) PN-3a: Blood Cultures Performed Within 24 Hours to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival 99.9 97.3 100.0 97.5 99.9 97.6 100.0 97.7 100.0 97.8 PN-3b: Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital 99.9 97.1 99.9 97.0 99.9 97.3 99.9 97.5 99.9 97.5 PN-6: Initial Antibiotic Selection for CAP in Immunocompetent Patient 99.8 94.8 99.7 94.6 99.8 94.8 99.8 95.1 99.8 95.0 Performance Measure Name The following graphs represent the information in the table above. The blue lines with diamond points (♦) represent the national rates and the dark red lines with square points (■) represent the benchmarks. PN-3a: Blood Cultures Performed Within 24 Hours to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival 100.0 PN-3b: Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital 100.0 95.0 95.0 90.0 90.0 85.0 85.0 80.0 80.0 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 PN-6: Initial Antibiotic Selection for CAP in Immunocompetent Patient 100.0 98.0 96.0 94.0 92.0 90.0 88.0 86.0 84.0 82.0 80.0 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 *ICU = Intensive Care Unit *CAP = Community Acquired Pneumonia *Qtr = Quarter HIQR Benchmarks and Trends - 3Q2012 Date Completed: May 15, 2013 Page 6 of 13 Benchmarks for Hospital-Abstracted Surgical Care Improvement Project (SCIP) Data - Third Quarter 2012 Using the ABC Technique* *The benchmarks reported here are unrelated to the 90th percentiles that are published on Hospital Compare for individual measures. Benchmark Rate (%) Numerator (Benchmark) Denominator (Benchmark) Number of Hospitals (Benchmark) National Rate (%) Numerator (National) Denominator (National) Number of Hospitals (National) SCIP-Inf-1: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision 99.9 25,478 25,498 100 98.5 248,678 252,377 3,539 SCIP-Inf-2: Prophylactic Antibiotic Selection for Surgical Patients 99.9 25,203 25,222 105 98.9 248,959 251,853 3,538 SCIP-Inf-3: Prophylactic Antibiotics Discontinued within 24 Hours After Surgery End Time 99.9 24,552 24,585 140 97.6 238,217 244,186 3,535 Performance Measure Name SCIP-Inf-4: Cardiac Surgery Patients With Controlled 6 AM Postoperative Blood Glucose SCIP-Inf-6: Surgery Patients with Appropriate Hair Removal 99.7 4,113 4,127 47 96.5 39,452 40,883 1,164 100.0 37,032 37,034 70 99.8 363,847 364,577 3,525 SCIP-Inf-9: Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero 99.8 19,913 19,948 103 96.3 191,122 198,422 3,461 SCIP-Inf-10: Surgery Patients with Perioperative Temperature Management 100.0 33,443 33,447 71 99.7 333,168 334,147 3,610 SCIP-CARD-2: Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a BetaBlocker During the Perioperative Period 99.9 11,470 11,480 92 97.3 111,064 114,201 3,375 SCIP-VTE-1: Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered 99.9 27,446 27,466 102 98.4 269,781 274,274 3,592 SCIP-VTE-2: Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours Prior to Surgery to 24 Hours After Surgery 99.9 27,741 27,760 138 97.7 267,653 273,941 3,587 *Benchmark Rate(%) is calculated using the Top 10% Sample. *National Rate(%) is calculated using the 100% Eligible Sample. *Selected references 1. Kiefe C I, Weissman N W, Allison J J, et al. Identifying achievable benchmarks of care: Concept and methodology. International Journal for Quality in Health Care 1998, vol 10 (5): 443-447. 2. Weissman N W, Allison J J, Kiefe C I, et al. Achievable benchmarks of care: the ABC's of benchmarking. Journal of Evaluation in Clinical Practice 1999, vol 5 (3): 269-281. 3. Allison J, Kiefe C I, Wessman N W. Can data-driven benchmarks be used to set goals of Healthy People 2010? American Journal of Public Health 1999, vol 89 (1): 61-65. 4. Allison J, Kiefe C I, Wessman N W, et al. Achievable benchmarks of care (ABC): User manual. Center for Outcome and Effectiveness Research and Education (COERE). University of Alabama at Birmingham. The benchmarks of care can be found on QualityNet at: https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228768205297 This material was prepared by Oklahoma Foundation for Medical Quality, Inc. (OFMQ), the Medicare Quality Improvement Organization for Oklahoma, under the Measures Development Special Studies contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SPOK01-1673-OK-0513 HIQR Benchmarks and Trends - 3Q2012 Date Completed: May 15, 2013 Page 7 of 13 Trends of Surgical Care Improvement Project (SCIP) Performance Measures and Benchmarks from Third Quarter 2011 to Third Quarter 2012 *The benchmarks reported here are unrelated to the 90th percentiles that are published on Hospital Compare for individual measures. Qtr 3 2011 Benchmark Rate (%) Qtr 3 2011 National Rate (%) Qtr 4 2011 Benchmark Rate (%) Qtr 4 2011 National Rate (%) Qtr 1 2012 Benchmark Rate (%) Qtr 1 2012 National Rate (%) Qtr 2 2012 Benchmark Rate (%) Qtr 2 2012 National Rate (%) Qtr 3 2012 Benchmark Rate (%) Qtr 3 2012 National Rate (%) SCIP-Inf-1: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision 99.9 98.1 99.9 98.2 99.9 98.4 99.9 98.5 99.9 98.5 SCIP-Inf-2: Prophylactic Antibiotic Selection for Surgical Patients 99.9 98.4 99.9 98.6 99.9 98.7 99.9 98.7 99.9 98.9 SCIP-Inf-3: Prophylactic Antibiotics Discontinued within 24 Hours After Surgery End Time 99.9 97.0 99.8 97.2 99.9 97.5 99.8 97.5 99.9 97.6 Performance Measure Name SCIP-Inf-4: Cardiac Surgery Patients With Controlled 6 AM Postoperative Blood Glucose SCIP-Inf-6: Surgery Patients with Appropriate Hair Removal 99.8 95.3 99.8 95.7 99.9 96.2 99.8 96.3 99.7 96.5 100.0 99.8 100.0 99.8 100.0 99.8 100.0 99.8 100.0 99.8 SCIP-Inf-9: Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero 99.8 94.5 99.8 95.2 99.9 95.5 99.9 96.0 99.8 96.3 SCIP-Inf-10: Surgery Patients with Perioperative Temperature Management 100.0 99.5 100.0 99.7 100.0 99.7 100.0 99.7 100.0 99.7 SCIP-CARD-2: Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period 99.9 96.4 99.9 96.8 99.8 96.5 99.9 97.0 99.9 97.3 SCIP-VTE-1: Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered 99.9 97.9 99.9 98.1 99.9 98.2 99.9 98.3 99.9 98.4 SCIP-VTE-2: Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours Prior to Surgery to 24 Hours After Surgery 99.9 97.1 99.9 97.3 99.9 97.6 99.9 97.7 99.9 97.7 The following graphs represent the information in the table above. The blue lines with diamond points (♦) represent the national rates and the dark red lines with square points (■) represent the benchmarks. SCIP-Inf-1: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision 100.0 95.0 90.0 85.0 80.0 SCIP-Inf-2: Prophylactic Antibiotic Selection for Surgical Patients 100.0 100.0 95.0 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 SCIP-Inf-3: Prophylactic Antibiotics Discontinued within 24 Hours After Surgery End Time 100.0 95.0 90.0 95.0 90.0 90.0 85.0 85.0 85.0 80.0 80.0 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 SCIP-Inf-4: Cardiac Surgery Patients With Controlled 6 AM Postoperative Blood Glucose 80.0 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 Graphs of SCIP trends continue on the following page. HIQR Benchmarks and Trends - 3Q2012 Date Completed: May 15, 2013 Page 8 of 13 Graphs of SCIP trends (continued) SCIP-Inf-9: Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero SCIP-Inf-6: Surgery Patients with Appropriate Hair Removal 100.0 100.0 95.0 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 Qtr 3 2011 85.0 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 80.0 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 SCIP-VTE-2: Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours Prior to Surgery to 24 Hours After Surgery SCIP-VTE-1: Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered 100.0 90.0 80.0 80.0 SCIP-CARD-2: Surgery Patients on BetaBlocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period 95.0 85.0 85.0 80.0 100.0 90.0 90.0 85.0 100.0 95.0 95.0 90.0 SCIP-Inf-10: Surgery Patients with Perioperative Temperature Management 100.0 95.0 95.0 90.0 90.0 85.0 85.0 80.0 80.0 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 *Abx = antibiotics *VTE = Venous Thromboembolism *Qtr = Quarter HIQR Benchmarks and Trends - 3Q2012 Date Completed: May 15, 2013 Page 9 of 13 Benchmarks for Hospital-Abstracted Immunization (IMM) Data - Third Quarter 2012 Using the ABC Technique* *The benchmarks reported here are unrelated to the 90th percentiles that are published on Hospital Compare for individual measures. Performance Measure Name IMM1-a: Pneumococcal Immunization - Overall Rate IMM-2: Influenza Immunization** Benchmark Rate (%) Numerator (Benchmark) Denominator (Benchmark) Number of Hospitals (Benchmark) 99.7 NA 49,223 NA 49,392 NA 325 NA National Rate (%) 88.7 NA Numerator (National) 436,130 NA Number of Denominator Hospitals (National) (National) 491,660 NA 3,690 NA Benchmark Rate(%) is calculated using the Top 10% Sample. National Rate(%) is calculated using the 100% Eligible Sample. **NA = Data not reported during this quarter (See algorithm) *Selected references 1. Kiefe C I, Weissman N W, Allison J J, et al. Identifying achievable benchmarks of care: Concept and methodology. International Journal for Quality in Health Care 1998, vol 10 (5): 443-447. 2. Weissman N W, Allison J J, Kiefe C I, et al. Achievable benchmarks of care: the ABC's of benchmarking. Journal of Evaluation in Clinical Practice 1999, vol 5 (3): 269-281. 3. Allison J, Kiefe C I, Wessman N W. Can data-driven benchmarks be used to set goals of Healthy People 2010? American Journal of Public Health 1999, vol 89 (1): 61-65. 4. Allison J, Kiefe C I, Wessman N W, et al. Achievable benchmarks of care (ABC): User manual. Center for Outcome and Effectiveness Research and Education (COERE). University of Alabama at Birmingham. The benchmarks of care can be found on QualityNet at: https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228768205297 This material was prepared by Oklahoma Foundation for Medical Quality, Inc. (OFMQ), the Medicare Quality Improvement Organization for Oklahoma, under the Measures Development Special Studies contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SPOK01-1673-OK-0513 HIQR Benchmarks and Trends - 3Q2012 Date Completed: May 15, 2013 Page 10 of 13 Trends of Immunization (IMM) Performance Measures and Benchmarks Third Quarter 2011 toThird Quarter 2012 *The benchmarks reported here are unrelated to the 90th percentiles that are published on Hospital Compare for individual measures. Values displayed are in minutes (smaller values are better performing) Qtr 3 2011 Benchmark Rate (%) Qtr 1 2012 Benchmark Rate (%) Qtr 1 2012 National Rate (%) Qtr 2 2012 Benchmark Rate (%) Qtr 2 2012 National Rate (%) Qtr 3 2012 Benchmark Rate (%) Qtr 3 2012 National Rate (%) IMM1-a: Pneumococcal Immunization Overall Rate 99.2 88.1 99.5 88.3 99.7 88.7 IMM-2: Influenza Immunization** 99.0 86.0 Performance Measure Name Qtr 3 2011 National Rate (%) Qtr 4 2011 Benchmark Rate (%) Qtr 4 2011 National Rate (%) The following graphs represent the information in the table above. The blue lines with diamond points (♦) represent the national rates and the dark red lines with square points (■) represent the benchmarks. IMM1-a: Pneumococcal Immunization Overall Rate IMM-2: Influenza Immunization** 100.0 100.0 95.0 95.0 90.0 90.0 85.0 85.0 80.0 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 80.0 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 Note: Each quarter consists of 3 months of data. *Qtr = Quarter **Data not reported for IMM-2 during this quarter (See algorithm) HIQR Benchmarks and Trends - 3Q2012 Date Completed: May 15, 2013 Page 11 of 13 Trends of Emergency Department (ED) Performance Measures and Benchmarks Provider Median Time Data - Third Quarter 2011 to Third Quarter 2012 *The benchmarks reported here are unrelated to the 90th percentiles that are published on Hospital Compare for individual measures. Values displayed are in minutes (smaller values are better performing) Qtr 3 2011 Benchmark Rate (%) Qtr 1 2012 Benchmark Rate (%) Qtr 1 2012 National Rate (%) Qtr 2 2012 Benchmark Rate (%) Qtr 2 2012 National Rate (%) Qtr 3 2012 Benchmark Rate (%) Qtr 3 2012 National Rate (%) ED-1b: Median Time from ED Arrival to ED Departure for Admitted ED Patients - Reporting Measure 260 175 256 176 257 178 ED-2b: Admit Decision Time to ED Departure Time for Admitted Patients - Reporting Measure 87 43 84 42 85 43 Performance Measure Name Qtr 3 2011 National Rate (%) Qtr 4 2011 Benchmark Rate (%) Qtr 4 2011 National Rate (%) The following graphs represent the information in the table above. The blue lines with diamond points (♦) represent the national median and the dark red lines with square points (■) represent the national top 10 percentile. 300 250 200 150 100 50 0 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 Mediann Time (mins) Median Time (mins) ED-1b: Median Time from ED Arrival to ED Departure for Admitted ED Patients Reporting Measure 100 ED-2b: Admit Decision Time to ED Departure Time for Admitted Patients - Reporting Measure 80 60 40 20 0 Qtr 3 2011 Qtr 4 2011 Qtr 1 2012 Qtr 2 2012 Qtr 3 2012 Note: Each quarter consists of 3 months of data. *Qtr = Quarter HIQR Benchmarks and Trends - 3Q2012 Date Completed: May 15, 2013 Page 12 of 13 Appropriate Care Measure (ACM) Benchmarks - Third Quarter 2012 for Hospital Abstracted Data – PPS Only Using the “ABC” Technique* *The benchmarks reported here are unrelated to the 90th percentiles that are published on Hospital Compare for individual measures. Benchmark Rate (%) Numerator (Benchmark) Denominator (Benchmark) Number of Hospitals (Benchmark) National Rate (%) Numerator (National) Denominator (National) Number of Hospitals (National) ACM for seven AMI HIQR measures 99.9 12,232 12,247 93 96.1 117,025 121,754 2,863 ACM for three HF HIQR measures 99.9 16,096 16,110 142 93.6 150,373 160,636 3,162 ACM for three PN HIQR measures 99.9 12,213 12,231 157 95.6 116,864 122,224 3,168 ACM for ten SCIP HIQR measures 99.2 36,928 37,217 246 92.3 343,473 372,057 3,175 ACM for one IMM HIQR measure 99.7 47,229 47,393 306 88.8 417,757 470,423 3,341 ACM for all 24 HIQR measures 98.8 123,900 125,439 316 91.9 1,145,492 1,247,094 3,399 Performance Measure Name *Benchmark Rate(%) is calculated using the Top 10% Sample. *National Rate(%) is calculated using the 100% Eligible Sample. Note: 24 RHQDAPU include: HF-1, HF-2, HF-3, AMI-1, AMI-2, AMI-3, AMI-5, AMI-7a, AMI-8a, AMI-10, PN-3a, PN-3b, PN-6, SCIP-1, SCIP-2, SCIP-3, SCIP-4, SCIP-6, SCIP-CARD2, SCIPVTE1, SCIP-VTE2, SCIP-9, SCIP-10, IMM-1a. *Selected references 1. Kiefe C I, Weissman N W, Allison J J, et al. Identifying achievable benchmarks of care: Concept and methodology. International Journal for Quality in Health Care 1998, vol 10 (5): 443-447. 2. Weissman N W, Allison J J, Kiefe C I, et al. Achievable benchmarks of care: the ABC's of benchmarking. Journal of Evaluation in Clinical Practice 1999, vol 5 (3): 269281. 3. Allison J, Kiefe C I, Wessman N W. Can data-driven benchmarks be used to set goals of Healthy People 2010? American Journal of Public Health 1999, vol 89 (1): 6165. 4. Allison J, Kiefe C I, Wessman N W, et al. Achievable benchmarks of care (ABC): User manual. Center for Outcome and Effectiveness Research and Education (COERE). University of Alabama at Birmingham. The benchmarks of care can be found on QualityNet at: https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228768205297 This material was prepared by Oklahoma Foundation for Medical Quality, Inc. (OFMQ), the Medicare Quality Improvement Organization for Oklahoma, under the Measures Development Special Studies contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SPOK01-1673-OK-0513 HIQR Benchmarks and Trends - 3Q2012 Date Completed: May 15, 2013 Page 13 of 13
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