| Oregon's Hospital Quality - Comments |
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| Intent and Use of Comments |
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Because the Oregon Hospital Quality Indicators are based on billing data, the results have limitations. There are many factors that determine health care outcomes that may not relate to hospital performance, but would influence the results presented here, for example, stage of illness, age, and other accompanying illnesses or conditions. Billing data does not provide every detail about a patient’s condition when he or she is admitted to the hospital, nor does it capture everything that occurs during the hospital stay.
The data analysis method attempts to adjust for some of these factors, but it is not possible to do so perfectly. For instance, when a patient has a Do Not Resuscitate (DNR) order in place, the hospital must honor that, and the data analysis software cannot differentiate between a death that occurs because a DNR was in place and one that occurs from some other cause.
Comments provided by the hospitals can more fully describe some of the factors involved in their results that may not be apparent otherwise. These comments also allow the hospitals to provide you with information about other quality initiatives with which they are involved as well as to link you to their internal quality websites.
Every hospital was afforded the opportunity to comment on their results, and we encourage you to read them.
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| Aortic Aneurysm (AAA) Repair |
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OHSU Comments on AAA Repair: Oregon Health & Science University is Oregon’s only academic medical center. OHSU is a respected regional resource because of the knowledge, expertise and leading-edge medical technology that is available at OHSU Hospital, Doernbecher Children’s Hospital, and their numerous clinics and specialized centers. Doctors from throughout Oregon refer patients to OHSU when the necessary level of care or expertise is not available closer to home. Because OHSU is one of two designated Level 1 trauma centers in Oregon, OHSU accepts many patients who are critically ill or injured. OHSU only transfers patients who no longer require its unique services and can be transferred to a hospital that is closer to their homes and can continue their care. www.OHSUhealth.com/ReportCards
What is an abdominal aortic aneurysm repair?
An abdominal aortic aneurysm is an abnormal enlargement of the lower portion of the large
artery that carries blood to the legs. This condition usually occurs in older people. Many of
these patients have a history of high blood pressure. Because an aneurysm can rupture and
cause serious and often fatal internal bleeding, this is a very serious condition.
Surgeons can repair the aneurysm to prevent a rupture. Sometimes, however, the doctor will
not discover the aneurysm until after it has ruptured. If the aneurysm ruptures, the patient will
need emergency surgery.
An abdominal aortic aneurysm repair is a major surgical procedure. The surgeon removes
the portion of the artery containing the aneurysm and replaces it with a synthetic tube. The
surgery is risky because blood flow to the lower body must stop while the doctor repairs the
aneurysm. There is also a chance of complications after surgery because these patients often
come to the hospital with extensive blood vessel damage in the legs and other parts of the
body.
OHSU expertise with abdominal aortic aneurysm repair
Patients who come to OHSU requiring an abdominal aortic aneurysm repair are often
severely ill, have complex medical conditions and need emergency medical care. Patients
and referring doctors choose OHSU because of its emergency medical and surgical
expertise.
OHSU results
In 27% of the patients who received an abdominal aortic aneurysm repair at OHSU in 2004,
the aneurysm had ruptured before the patient arrived. The statewide rupture rate was 16%.
Of the patients who came to OHSU for an abdominal aortic aneurysm repair:
- 37% were admitted from the emergency department
- 14% were transferred from other hospitals
OHSU performed 30 operations in 2004. This number is nearly equal to the 32 operations
the State recommends as demonstrating experience with this type of surgery.
OHSU results compared with other Oregon hospitals
The death rate for patients who received an abdominal aortic aneurysm repair at OHSU in
2004 was 21%, which is significantly higher than the State average. This is because OHSU
accepts patients who are admitted through its emergency department, as well as those who
have been transferred from other hospitals because of their high risk of death. For elective
(non-emergent) surgeries, OHSU’s death rate was 10.5%. The death rate was 45% for
patients who arrived at OHSU with ruptured aneurysms, including patients transferred to
OHSU from other hospitals and patients admitted from the Emergency Department. This
rate reflects the desperately ill condition of this group of patients upon arrival at OHSU.
When compared to other academic medical centers that care for a similar group of patients,
OHSU’s death rates are comparable.
OHSU’s experience with abdominal aortic aneurysm repair in 2005 has been excellent. Of
the 13 surgeries performed at OHSU through May 2005, no patients have died.
| Sacred Heart Medical Center |
Sacred Heart Medical Center Comments on AAA Repair: Sacred Heart Medical Center (SHMC) reviewed the Abdominal Aortic Aneurysm Repair volume information reported on this website, as the reported rate was much lower than our known aortic aneurysm repair rate. A coding issue was identified and confirmed for this 2004 data. The corrected and accurate abdominal aortic aneurysm repair volume was 43 for 2004, placing Sacred Heart above the volume threshold suggested by OHPR/AHRQ. This is a good example of the need for caution in interpreting quality indicators using administrative data. SHMC welcomes the opportunity given by OHPR to comment on this data and provide an explanation.
SHMC maintains an active program to review the outcomes of care provided to its patients; and philosophically believes that being open and honest - transparent - about the care received by its patients, ultimately leads to ongoing improvements in care. To view SHMC's Transparency Website demonstrating the results of care provided at SHMC and what we are doing about it, please visit http://www.peacehealth.org/apps/quality/QFacilityReport.asp?Hospital=2
Comments last updated: July 8, 2005
Tuality Healthcare Comments on AAA Repair: Tuality Healthcare maintains an ongoing, strong commitment to Quality Improvement (QI) in patient care and other areas of operation. Tuality is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the College of American Pathologists (CAP). In compliance with JCAHO and CAP standards, Tuality continually monitors, collects and communicates numerous quality indicators. Tuality also fully complies with federal quality regulations established by the Centers for Medicare and Medicaid Services. In addition, Tuality openly participates in supplementary QI initiatives that help ensure positive patient outcomes, such as the “100,000 Lives Campaign” of the VHA and Institute for Health Care Quality.
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| Balloon Angioplasty (PTCA) |
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OHSU Comments on Balloon Angioplasty: Oregon Health & Science University is Oregon’s only academic medical center. OHSU is a respected regional resource because of the knowledge, expertise and leading-edge medical technology that is available at OHSU Hospital, Doernbecher Children’s Hospital, and their numerous clinics and specialized centers. Doctors from throughout Oregon refer patients to OHSU when the necessary level of care or expertise is not available closer to home. Because OHSU is one of two designated Level 1 trauma centers in Oregon, OHSU accepts many patients who are critically ill or injured. OHSU only transfers patients who no longer require its unique services and can be tranferred to a hospital that is closer to their homes and can continue their care. www.OHSUhealth.com/ReportCards
What is balloon angioplasty (also known as percutaneous transluminal coronary
angioplasty)?
Balloon angioplasty is a specialized procedure in which a thin tube (catheter) is threaded
through the body’s blood vessels into the heart. The catheter has an inflatable balloon at its
tip. The balloon expands the blocked portion of the artery to improve or restore blood flow
to the heart. Doctors can also insert expandable metal tubes (known as stents) through the
catheter to help keep the blocked artery open. The balloon angioplasty relieves symptoms,
such as anginal chest pain, and prevents future heart attacks.
If a patient is having an acute heart attack, cardiologists may have to perform this surgery as
an emergency procedure, which is more risky. Sometimes the blockage immediately recurs.
If this happens, doctors must perform a more complicated open-heart surgery to repair the
blockage.
OHSU expertise with balloon angioplasty
Patients and referring providers throughout Oregon recognize OHSU’s cardiac expertise.
Because of its emergency medicine expertise, patients who are having acute heart attacks
often come to OHSU for care.
OHSU results
In 2004 94% of the patients who had balloon angioplasty at OHSU were admitted to the
hospital from the emergency department. This is in comparison to 25% of the cases
statewide. Although the patients undergoing balloon angioplasty at OHSU are often severely
ill, OHSU’s results are very good.
OHSU results compared to other Oregon hospitals
Although other Oregon hospitals tend to perform this procedure as a scheduled or elective
surgery rather than on an emergency basis as is the case at OHSU, OHSU’s post-
procedure death rate (2.1%) is not significantly different from that of other Oregon hospitals
(1.4%).
| Sacred Heart Medical Center |
Sacred Heart Medical Center Comments on Balloon Angioplasty: Sacred Heart Medical Center is committed to Transparency, which we define as being open and honest about the safety, quality, and level of patient satisfaction related to the care we provide as a means of fulfilling our promise to deliver exceptional medicine and compassionate care http://www.peacehealth.org/AboutPH/OurPromise.htm.
Public quality data on Sacred Heart performance can be found at a number of websites: the Joint Commission Hospital Quality Check website ( http://www.jcaho.org/); the Center for Medicare and Medicaid Services Hospital Compare website ( http://www.hospitalcompare.hhs.gov/); and the Oregon Pricepoint website ( http://www.orpricepoint.org/). If you study these sites, you will find some differences in reported numbers. This is because each performance chart may use different time periods, different data sets, different specifications, and different risk adjustment methods. Finally, it bears repeating that these indicators must be used cautiously, because the administrative data on which the indicators are based are not collected for research purposes or for measuring quality of care, but for billing purposes. Nevertheless, this information can be used to launch explorations into reasons for potential quality problems, and that is exactly what Sacred Heart Medical Center does and takes seriously.
Sacred Heart Medical Center's Center for Healthcare Improvement has many personnel dedicated to reviewing and investigating all quality indicators from whatever source, and facilitating clinical improvements.
Comments last updated: July 8, 2005
Tuality Healthcare Comments on Balloon Angioplasty: Tuality Healthcare maintains an ongoing, strong commitment to Quality Improvement (QI) in patient care and other areas of operation. Tuality is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the College of American Pathologists (CAP). In compliance with JCAHO and CAP standards, Tuality continually monitors, collects and communicates numerous quality indicators. Tuality also fully complies with federal quality regulations established by the Centers for Medicare and Medicaid Services. In addition, Tuality openly participates in supplementary QI initiatives that help ensure positive patient outcomes, such as the “100,000 Lives Campaign” of the VHA and Institute for Health Care Quality.
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| Heart Bypass Surgery (CABG) |
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Legacy Health System Comments on Heart Bypass Surgery (CABG):
Why is the CABG mortality rate higher at LegacyGood Samaritan Hospital? We have identified one important reason for this finding. Good Samaritan surgeons perform a higher proportion of “combination” surgeries than any other hospital in the state. These are surgeries where not only is a CABG performed, but the patient undergoes one or more heart valve replacements. These patients are much sicker and the surgery is riskier, with a significantly higher mortality rate. Of note is that the same group of surgeons also perform the heart surgeries at Legacy Emanuel, where the mortality rate is within the expected range. They tend to take the sicker patients to Good Samaritan for the more complex operations.
How is Legacy managing its quality processes?
Legacy staff regularly monitor mortality rates, along with many other indicators of care quality, in their efforts to provide the highest and safest care quality. Teams of physicians, nurses and administrators are constantly looking for new and better ways to reduce medication errors, infections, and other complications of the complex care processes provided in the hospital. Data such as these have long been part of that process and are viewed as an important part of our quality efforts.
How good a measure of quality is mortality?Reported mortality rates for hospitals represent a complex mix of factors. Most importantly, it has been shown that patient factors, such as severity of illness or pre-existing conditions, such as diabetes or heart failure, are the most powerful predictor of mortality rates. Often, institutions vary widely in what kind of patients they see and what patients are selected to undergo various treatments. A large, complex institution will tend to see sicker, more complex patients, as a rule. Thus, mortality rates for surgical procedures are often higher in tertiary care facilities. This is called patient selection bias. Severity-adjustment tools help correct for this kind of bias, but they are inexact. There are a variety of risk adjustment tools in existence, and we have seen as much as a 2-fold difference in expected mortality rates, depending on which risk adjustment tool is used.
OHSU Comments on Heart Bypass Surgery (CABG): Oregon Health & Science University is Oregon’s only academic medical center. OHSU is a respected regional resource because of the knowledge, expertise and leading-edge medical technology that is available at OHSU Hospital, Doernbecher Children’s Hospital, and their numerous clinics and specialized centers. Doctors from throughout Oregon refer patients to OHSU when the necessary level of care or expertise is not available closer to home. Because OHSU is one of two designated Level 1 trauma centers in Oregon, OHSU accepts many patients who are critically ill or injured. OHSU only transfers patients who no longer require its unique services and can be tranferred to a hospital that is closer to their homes and can continue their care. www.OHSUhealth.com/ReportCards
What is coronary artery bypass graft surgery?
In coronary artery bypass graft surgery, the surgeon removes a section of a patient’s blood
vessel from another part of the body and makes a bypass so blood can travel around a
blockage in an artery to the heart. The surgery relieves symptoms, such as anginal chest pain,
and prevents future heart attacks.
This surgery may be risky because the surgeon must stop the heart while creating the bypass.
Risk increases if a patient who needs this type of surgery also has other serious diseases
such as high blood pressure, diabetes mellitus and blood vessel blockages in the brain and
other parts of the body. If the patient is suffering an acute heart attack, the surgeon must
perform this type of surgery as an emergency procedure, which is even riskier.
OHSU expertise with coronary artery bypass graft surgery
Patients and referring providers throughout Oregon recognize OHSU’s expertise in cardiac
surgery. Patients who come to OHSU because they are having an acute heart attack or their
condition is deteriorating and may soon have a heart attack are often severely ill. Therefore,
while most hospitals in Oregon perform this type of surgery on a scheduled or elective basis,
OHSU often performs it on an emergency basis.
OHSU results
In 2004 66% of the patients who came to OHSU for coronary artery bypass graft surgery
were admitted to the hospital from the emergency department. This is significantly higher than
the statewide average of 15%.
OHSU results compared with other Oregon hospitals
Despite the severity of the patients who come to OHSU for coronary artery bypass graft
surgery, OHSU’s results are very good. OHSU’s post-operative death rate of 4% is not
significantly different from that of other Oregon hospitals (3.4%).
| Sacred Heart Medical Center |
Sacred Heart Medical Center Comments on CABG: Sacred Heart Medical Center is committed to Transparency, which we define as being open and honest about the safety, quality, and level of patient satisfaction related to the care we provide as a means of fulfilling our promise to deliver exceptional medicine and compassionate care. http://www.peacehealth.org/AboutPH/OurPromise.htm.
Our providers, patients, and the communities we serve deserve to know how we're doing, because it's the right thing to do and because that's how we learn and improve. The link to Sacred Heart's transparency site can be found at http://www.peacehealth.org/apps/quality/QFacilityReport.asp?Hospital=2.
Public quality data on Sacred Heart performance can be found at a number of websites: the Joint Commission Hospital Quality Check website (http://www.jcaho.org/); the Center for Medicare and Medicaid Services Hospital Compare website (http://www.hospitalcompare.hhs.gov/); and the Oregon Pricepoint website (http://www.orpricepoint.org/). If you study these sites, you will find some differences in reported numbers. This is because each performance chart may use different time periods, different data sets, different specifications, and different risk adjustment methods. Finally, it bears repeating that these indicators must be used cautiously, because the administrative data on which the indicators are based are not collected for research purposes or for measuring quality of care, but for billing purposes. Nevertheless, this information can be used to launch explorations into reasons for potential quality problems, and that is exactly what Sacred Heart Medical Center does and takes seriously.
Sacred Heart Medical Center's Center for Healthcare Improvement has many personnel dedicated to reviewing and investigating all quality indicators from whatever source, and facilitating clinical improvements.
Comments last updated: July 8, 2005
Tuality Healthcare Comments on CABG: Tuality Healthcare maintains an ongoing, strong commitment to Quality Improvement (QI) in patient care and other areas of operation. Tuality is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the College of American Pathologists (CAP). In compliance with JCAHO and CAP standards, Tuality continually monitors, collects and communicates numerous quality indicators. Tuality also fully complies with federal quality regulations established by the Centers for Medicare and Medicaid Services. In addition, Tuality openly participates in supplementary QI initiatives that help ensure positive patient outcomes, such as the “100,000 Lives Campaign” of the VHA and Institute for Health Care Quality.
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| Carotid Endarterectomy (CEA) |
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| Mid Columbia Medical Center |
Mid Columbia Medical Center Comments on Carotid Endarterectomy: The quality of care provided to the patients at Mid-Columbia Medical Center is of utmost importance to us. If, as you review this information, you have any questions please contact the Performance and Quality Department by calling 541-296-7380 or by email at pqs@mcmc.net.
OHSU Comments on Carotid Endarterectomy: Oregon Health & Science University is Oregon’s only academic medical center. OHSU is a respected regional resource because of the knowledge, expertise and leading-edge medical technology that is available at OHSU Hospital, Doernbecher Children’s Hospital, and their numerous clinics and specialized centers. Doctors from throughout Oregon refer patients to OHSU when the necessary level of care or expertise is not available closer to home. Because OHSU is one of two designated Level 1 trauma centers in Oregon, OHSU accepts many patients who are critically ill or injured. OHSU only transfers patients who no longer require its unique services and can be tranferred to a hospital that is closer to their homes and can continue their care. www.OHSUhealth.com/ReportCards
What is a carotid endarterectomy?
A carotid endarterectomy (CEA) is a surgical procedure to repair a blockage in one of the
major arteries that carries blood to the brain. A patient with this type of blockage has a high
risk of having a serious stroke. Surgery to repair the blockage helps prevent a stroke.
Doctors who are involved in this type of procedure have special training in interventional
radiology, vascular surgery or vascular medicine.
OHSU expertise with carotid endarterectomy
OHSU has great expertise in vascular surgery and interventional radiology. Physicians from
across Oregon refer patients who have blocked carotid arteries to OHSU to give them the
benefit of this expertise.
Many patients may not require an open surgical procedure. At OHSU, specialists are able to
perform a less-invasive procedure in which they insert a balloon catheter into the artery to
open the blockage. The catheter is similar to the one doctors use to open a heart blockage.
Some patients who have particularly difficult blockages, however, may require an open
procedure. Both options are available at OHSU.
OHSU results
The measure reported in this Web site refers to patients who require an open surgical
procedure. OHSU has had excellent results in both 2003 and 2004. During that two-year
period, no patients who required this procedure died during the post-operative period. This
is a 0% death rate.
OHSU results compared to other Oregon hospitals
OHSU’s results were better on average than other Oregon hospitals.
| Rogue Valley Medical Center |
Rogue Valley Medical Center Comments on Carotid Endarterectomy: This AHRQ Quality Indicator represents the current state-of-the-art in assessing quality of care using hospital administrative data. However, this indicator must be used cautiously, because the administrative data on which the indicator is based is not collected for research purposes or for measuring quality of care, but for billing purposes. While these data are relatively inexpensive and convenient to use—and represent a rich data source that can provide valuable information—they should not be used as a definitive source of information on quality of health care. At least three limitations of administrative data warrant caution:
- Coding of information is different across hospitals. Some hospitals code more thoroughly than others, making “fair” comparisons across hospitals difficult.
- Ambiguity about when a condition occurs. Most administrative data cannot distinguish unambiguously whether a specific condition was present at admission or whether it occurred during the stay (i.e., a possible complication).
- The codes themselves are often not specific enough to adequately characterize a patient’s condition, which makes it impossible to perfectly risk-adjust any administrative data set, thus fair comparisons across hospitals become difficult.
The mortality measure should not be examined independently, because it did not meet the literature review and empirical evaluation criteria to stand alone as its own measure.
Rogue Valley Medical Center is a regional referral center for southern Oregon and northern California. The average age of residents in Jackson County is higher than the state average, and may be a contributing factor to the higher mortality. All in-hospital mortalities are reviewed for improvement purposes.
Comments last updated: June 30, 2005
| Sacred Heart Medical Center |
Sacred Heart Medical Center Comments on Carotid Endarterectomy:Sacred Heart Medical Center is committed to Transparency, which we define as being open and honest about the safety, quality, and level of patient satisfaction related to the care we provide as a means of fulfilling our promise to deliver exceptional medicine and compassionate care. http://www.peacehealth.org/AboutPH/OurPromise.htm.
Our providers, patients, and the communities we serve deserve to know how we're doing, because it's the right thing to do and because that's how we learn and improve. The link to Sacred Heart's transparency site can be found at http://www.peacehealth.org/apps/quality/QFacilityReport.asp?Hospital=2.
Public quality data on Sacred Heart performance can be found at a number of websites: the Joint Commission Hospital Quality Check website ( http://www.jcaho.org/); the Center for Medicare and Medicaid Services Hospital Compare website ( http://www.hospitalcompare.hhs.gov/); and the Oregon Pricepoint website ( http://www.orpricepoint.org/). If you study these sites, you will find some differences in reported numbers. This is because each performance chart may use different time periods, different data sets, different specifications, and different risk adjustment methods. Finally, it bears repeating that these indicators must be used cautiously, because the administrative data on which the indicators are based are not collected for research purposes or for measuring quality of care, but for billing purposes. Nevertheless, this information can be used to launch explorations into reasons for potential quality problems, and that is exactly what Sacred Heart Medical Center does and takes seriously.
Sacred Heart Medical Center's Center for Healthcare Improvement has many personnel dedicated to reviewing and investigating all quality indicators from whatever source, and facilitating clinical improvements.
Comments last updated: July 8, 2005
Samaritan Albany General Hospital
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Samaritan Albany General Hospital Comments on Carotid Endarterectomy: Samaritan Albany General Hospital has performed 38 Carotid Endarterectomy procedures in 2004 as compared to the reported case volume of 19 patients on this website.
| Three Rivers Community Hospital |
Three Rivers Community Hospital Comments on Carotid Endarterectomy: This AHRQ Quality Indicator represents the current state-of-the-art in assessing quality of care using hospital administrative data. However, this indicator must be used cautiously, because the administrative data on which the indicator is based is not collected for research purposes or for measuring quality of care, but for billing purposes. While these data are relatively inexpensive and convenient to use—and represent a rich data source that can provide valuable information—they should not be used as a definitive source of information on quality of health care. At least three limitations of administrative data warrant caution:
- Coding of information is different across hospitals. Some hospitals code more thoroughly than others, making “fair” comparisons across hospitals difficult.
- Ambiguity about when a condition occurs. Most administrative data cannot distinguish unambiguously whether a specific condition was present at admission or whether it occurred during the stay (i.e., a possible complication).
- The codes themselves are often not specific enough to adequately characterize a patient’s condition, which makes it impossible to perfectly risk-adjust any administrative data set, thus fair comparisons across hospitals become difficult.
The mortality measure should not be examined independently, because it did not meet the literature review and empirical evaluation criteria to stand alone as its own measure.
The average age of residents in Josephine County is higher than the state average, and may be a contributing factor to the higher mortality. All in-hospital mortalities are reviewed for improvement purposes.
Comments last updated: June 30, 2005
Tuality Healthcare Comments on Carotid Endarterectomy: Tuality Healthcare maintains an ongoing, strong commitment to Quality Improvement (QI) in patient care and other areas of operation. Tuality is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the College of American Pathologists (CAP). In compliance with JCAHO and CAP standards, Tuality continually monitors, collects and communicates numerous quality indicators. Tuality also fully complies with federal quality regulations established by the Centers for Medicare and Medicaid Services. In addition, Tuality openly participates in supplementary QI initiatives that help ensure positive patient outcomes, such as the “100,000 Lives Campaign” of the VHA and Institute for Health Care Quality.
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| Esophageal Resection |
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OHSU Comments on Esophageal Resection: Oregon Health & Science University is Oregon’s only academic medical center. OHSU is a respected regional resource because of the knowledge, expertise and leading-edge medical technology that is available at OHSU Hospital, Doernbecher Children’s Hospital, and their numerous clinics and specialized centers. Doctors from throughout Oregon refer patients to OHSU when the necessary level of care or expertise is not available closer to home. Because OHSU is one of two designated Level 1 trauma centers in Oregon, OHSU accepts many patients who are critically ill or injured. OHSU only transfers patients who no longer require its unique services and can be tranferred to a hospital that is closer to their homes and can continue their care. www.OHSUhealth.com/ReportCards
What is an esophageal resection?
An esophageal resection is very specialized surgery to remove a section of the esophagus,
the tube that carries food and liquids from the mouth to the stomach.
OHSU expertise with esophageal resection
OHSU surgeons have the necessary skills to achieve outstanding outcomes for patients who
require surgery on their digestive systems. They have specific expertise in esophageal
resections.
OHSU results
In 2004 surgeons at OHSU operated on 17 patients who needed an esophageal resection.
This was 40% of all esophageal resections performed in Oregon. That number is more than
double the seven procedures the State recommends as demonstrating experience with this
type of surgery.
In 2004 none of the patients who had an esophageal resections died during the post-
operative period. This is a 0% death rate.
OHSU results compared to other Oregon hospitals
OHSU’s results were far better than Oregon’s death rate of 9.4% and the national death
rate of 9.5%.
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| Heart Attack (AMI) |
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| Mid Columbia Medical Center |
Mid Columbia Medical Center Comments on Heart Attack: The quality of care provided to the patients at Mid-Columbia Medical Center is of utmost importance to us. If, as you review this information, you have any questions please contact the Performance and Quality Department by calling 541-296-7380 or by email at pqs@mcmc.net.
OHSU Comments on Heart Attack: Oregon Health & Science University is Oregon’s only academic medical center. OHSU is a respected regional resource because of the knowledge, expertise and leading-edge medical technology that is available at OHSU Hospital, Doernbecher Children’s Hospital, and their numerous clinics and specialized centers. Doctors from throughout Oregon refer patients to OHSU when the necessary level of care or expertise is not available closer to home. Because OHSU is one of two designated Level 1 trauma centers in Oregon, OHSU accepts many patients who are critically ill or injured. OHSU only transfers patients who no longer require its unique services and can be tranferred to a hospital that is closer to their homes and can continue their care. www.OHSUhealth.com/ReportCards
What is a heart attack?
A heart attack occurs when a blockage develops in one of the arteries that supply blood to
the heart. The blockage prevents blood flow and causes damage to the heart. When the
damage is severe, the heart has to work harder to pump blood. In severe cases, the heart
stops pumping and the patient may die. Skilled medical care immediately after a heart attack
can reduce the risk of death.
OHSU expertise with heart attack
OHSU has an extremely effective program for providing medical care to patients who have
heart problems.
OHSU results compared with other Oregon hospitals
In 2004 patients who were admitted to OHSU Hospital for a heart attack (acute myocardial
infarction) had a lower death rate (6.1%) than those who were treated in other Oregon
hospitals statewide (9.8%).
| Providence Newberg Hospital |
Providence Newberg Hospital Comments on Heart Attack: Most patients are transferred to a tertiary care hospital for cardiac catheterization or open-heart surgery. In many cases, those patients who are not transferred have other serious illnesses that preclude cardiac surgery. A lot of the patients have DNR status on admission.
Comments last updated: June 24, 2005
| Rogue Valley Medical Center |
Rogue Valley Medical Center Comments on Heart Attack: This AHRQ Quality Indicator represents the current state-of-the-art in assessing quality of care using hospital administrative data. However, this indicator must be used cautiously, because the administrative data on which the indicator is based is not collected for research purposes or for measuring quality of care, but for billing purposes. While these data are relatively inexpensive and convenient to use—and represent a rich data source that can provide valuable information—they should not be used as a definitive source of information on quality of health care. At least three limitations of administrative data warrant caution:
- Coding of information is different across hospitals. Some hospitals code more thoroughly than others, making “fair” comparisons across hospitals difficult.
- Ambiguity about when a condition occurs. Most administrative data cannot distinguish unambiguously whether a specific condition was present at admission or whether it occurred during the stay (i.e., a possible complication).
- The codes themselves are often not specific enough to adequately characterize a patient’s condition, which makes it impossible to perfectly risk-adjust any administrative data set, thus fair comparisons across hospitals become difficult.
Rogue Valley Medical Center is a regional referral center for southern Oregon and northern California. The average age of residents in Jackson County is higher than the state average, and may be a contributing factor to the higher mortality. In addition, Rogue Valley Medical Center is the target hospital for the ASSET program. In this program, patients having a heart attack and needing the services of a cardiac catheterization laboratory are immediately brought to Rogue Valley Medical Center, bypassing other hospitals without the necessary cardiac care facilities. All in-hospital mortalities are reviewed for improvement purposes.
Comments last updated: June 30, 2005
| Sacred Heart Medical Center |
Sacred Heart Medical Center Comments on Heart Attack: Sacred Heart Medical Center is committed to Transparency, which we define as being open and honest about the safety, quality, and level of patient satisfaction related to the care we provide as a means of fulfilling our promise to deliver exceptional medicine and compassionate care. http://www.peacehealth.org/AboutPH/OurPromise.htm.
Public quality data on Sacred Heart performance can be found at a number of websites: the Joint Commission Hospital Quality Check website ( http://www.jcaho.org/); the Center for Medicare and Medicaid Services Hospital Compare website ( http://www.hospitalcompare.hhs.gov/); and the Oregon Pricepoint website ( http://www.orpricepoint.org/). If you study these sites, you will find some differences in reported numbers. This is because each performance chart may use different time periods, different data sets, different specifications, and different risk adjustment methods. Finally, it bears repeating that these indicators must be used cautiously, because the administrative data on which the indicators are based are not collected for research purposes or for measuring quality of care, but for billing purposes. Nevertheless, this information can be used to launch explorations into reasons for potential quality problems, and that is exactly what Sacred Heart Medical Center does and takes seriously.
Sacred Heart Medical Center's Center for Healthcare Improvement has many personnel dedicated to reviewing and investigating all quality indicators from whatever source, and facilitating clinical improvements.
Comments last updated: July 8, 2005
| Samaritan Albany General Hospital |
Samaritan Albany General Hospital Comments on Heart Attack: The mortality rate for patients having an acute myocardial infarction is high at Samaritan Albany General Hospital, due to the fact that we transfer all patients who are possible candidates for cardiac surgery to other hospitals as quickly as possible. We do not perform cardiac surgery at this hospital. The only patients with acute myocardial infarction that are treated at this hospital are high-risk patients who are not candidates for surgery, they have multiple problems, and generally there is nothing more that can be done to treat them.
The small number of acute MI patients treated at SAGH receive high quality care as reported on the www.hospitalcompare.hhs.gov website.
| Three Rivers Community Hospital |
Three Rivers Community Hospital Comments on Heart Attack: This AHRQ Quality Indicator represents the current state-of-the-art in assessing quality of care using hospital administrative data. However, this indicator must be used cautiously, because the administrative data on which the indicator is based is not collected for research purposes or for measuring quality of care, but for billing purposes. While these data are relatively inexpensive and convenient to use—and represent a rich data source that can provide valuable information—they should not be used as a definitive source of information on quality of health care. At least three limitations of administrative data warrant caution:
- Coding of information is different across hospitals. Some hospitals code more thoroughly than others, making “fair” comparisons across hospitals difficult.
- Ambiguity about when a condition occurs. Most administrative data cannot distinguish unambiguously whether a specific condition was present at admission or whether it occurred during the stay (i.e., a possible complication).
- The codes themselves are often not specific enough to adequately characterize a patient’s condition, which makes it impossible to perfectly risk-adjust any administrative data set, thus fair comparisons across hospitals become difficult.
The average age of residents in Josephine County is higher than the state average, and may be a contributing factor to the higher mortality. All in-hospital mortalities are reviewed for improvement purposes.
Comments last updated: June 30, 2005
Tuality Healthcare Comments on Heart Attack: Tuality Healthcare maintains an ongoing, strong commitment to Quality Improvement (QI) in patient care and other areas of operation. Tuality is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the College of American Pathologists (CAP). In compliance with JCAHO and CAP standards, Tuality continually monitors, collects and communicates numerous quality indicators. Tuality also fully complies with federal quality regulations established by the Centers for Medicare and Medicaid Services. In addition, Tuality openly participates in supplementary QI initiatives that help ensure positive patient outcomes, such as the “100,000 Lives Campaign” of the VHA and Institute for Health Care Quality.
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| Heart Failure (CHF) |
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Mid Columbia Medical Center
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Mid Columbia Medical Center Comments on Heart Failure: The quality of care provided to the patients at Mid-Columbia Medical Center is of utmost importance to us. If, as you review this information, you have any questions please contact the Performance and Quality Department by calling 541-296-7380 or by email at pqs@mcmc.net.
OHSU Comments on Heart Failure: Oregon Health & Science University is Oregon’s only academic medical center. OHSU is a respected regional resource because of the knowledge, expertise and leading-edge medical technology that is available at OHSU Hospital, Doernbecher Children’s Hospital, and their numerous clinics and specialized centers. Doctors from throughout Oregon refer patients to OHSU when the necessary level of care or expertise is not available closer to home. Because OHSU is one of two designated Level 1 trauma centers in Oregon, OHSU accepts many patients who are critically ill or injured. OHSU only transfers patients who no longer require its unique services and can be tranferred to a hospital that is closer to their homes and can continue their care. www.OHSUhealth.com/ReportCards
What is heart failure?
Heart failure is a condition in which damage to the heart muscle prevents the heart from
pumping enough blood to meet the body’s needs. Heart failure causes fluid to build up in the
lungs and in other parts of the body. This condition can affect the lungs, kidneys and other
important body organs. Patients who have severe heart failure may require placement of
mechanical pumps to stay alive. Ultimately, these patients may require a heart transplant.
Doctors will carefully evaluate patients who have heart failure to understand the causes of the
heart problem. They will use various medications to improve the condition.
OHSU expertise with heart failure
OHSU has a highly skilled team of cardiac specialists who have routinely been recognized
for their level of expertise. OHSU has one of two heart transplant programs in Oregon. The
team has a high level of success in treating patients with heart failure.
OHSU results compared to other Oregon hospitals
Patients admitted to OHSU Hospital for heart failure in 2004 had a lower death rate (4.4
%), when compared to patients admitted to other Oregon hospitals (4.6%). When
compared to other university medical centers that also care for patients with severe heart
failure, the death rate at OHSU was lower.
| Sacred Heart Medical Center |
Sacred Heart Medical Center Comments on Heart Failure: Sacred Heart Medical Center is committed to Transparency, which we define as being open and honest about the safety, quality, and level of patient satisfaction related to the care we provide as a means of fulfilling our promise to deliver exceptional medicine and compassionate care. http://www.peacehealth.org/AboutPH/OurPromise.htm.
Our providers, patients, and the communities we serve deserve to know how we're doing, because it's the right thing to do and because that's how we learn and improve. The link to Sacred Heart's transparency site can be found at http://www.peacehealth.org/apps/quality/QFacilityReport.asp?Hospital=2.
Public quality data on Sacred Heart performance can be found at a number of websites: the Joint Commission Hospital Quality Check website (http://www.jcaho.org/); the Center for Medicare and Medicaid Services Hospital Compare website (http://www.hospitalcompare.hhs.gov/); and the Oregon Pricepoint website (http://www.orpricepoint.org/). If you study these sites, you will find some differences in reported numbers. This is because each performance chart may use different time periods, different data sets, different specifications, and different risk adjustment methods. Finally, it bears repeating that these indicators must be used cautiously, because the administrative data on which the indicators are based are not collected for research purposes or for measuring quality of care, but for billing purposes. Nevertheless, this information can be used to launch explorations into reasons for potential quality problems, and that is exactly what Sacred Heart Medical Center does and takes seriously.
Sacred Heart Medical Center's Center for Healthcare Improvement has many personnel dedicated to reviewing and investigating all quality indicators from whatever source, and facilitating clinical improvements.
Comments last updated: July 8, 2005
| Samaritan North Lincoln Hospital |
Samaritan North Lincoln Hospital Comments on Heart Failure: Rural hospitals do not have the same volume of patients as hospitals in larger communities, so it is difficult to make meaningful comparisons between the two. Patients requiring a higher level of care are transferred to a larger facility, further decreasing the volume for comparison for these indicators.
- The population of Lincoln County contains a higher percentage than most counties in the state of people 65 and older. These people are more likely to suffer from cardiac & vascular problems as well as cancer, diabetes and other chronic diseases.
- People in the last stages of their illness often request comfort care in the local hospital setting. This supports patients and their families in death with dignity.
- Quality initiatives and performance improvement projects are ongoing in our facilities. At any given time there are typically over 100 initiatives underway. Some of these include:
- National Patient Safety Goals – We support these with specific action plans and by auditing our progress.
- Core Measures – We participate in this national voluntary public reporting project. We track and report certain measures for patients with Acute Myocardial Infarction (AMI or heart attack); Heart Failure; Pneumonia, and prevention of surgical infections. See our results on the Internet at http://www.hospitalcompare.hhs.gov/
- Cardiac Performance Improvement Project – this collaborative project includes ambulance staff, hospital staff and physicians, and cardiovascular staff and physicians at Good Samaritan Regional Medical Center (GSRMC). The team has evaluated transfer times from the coast to the cardiac center at GSRMC. Multiple actions were taken to reduce transfer times by 20%. The team is now focused on educational outreach to teach people to seek care much more quickly so heart muscle can be saved.
| Samaritan Pacific Communities Hospital |
Samaritan Pacific Communities Hospital Comments on Heart Failure: Rural hospitals do not have the same volume of patients as hospitals in larger communities, so it is difficult to make meaningful comparisons between the two. Patients requiring a higher level of care are transferred to a larger facility, further decreasing the volume for comparison for these indicators.
- The population of Lincoln County contains a higher percentage than most counties in Oregon of people 65 and older. These people are more likely to suffer from cardiac & vascular problems as well as cancer, diabetes and other chronic diseases.
- People in the last stages of their illness often request comfort care in the local hospital setting. This supports patients and their families in death with dignity.
- Quality initiatives and performance improvement projects are ongoing in our facilities. At any given time there are typically over 100 initiatives underway. Some of these include:
- National Patient Safety Goals – We support these with specific action plans and by auditing our progress.
- Core Measures – We participate in this national voluntary public reporting project. We track and report certain measures for patients with Acute Myocardial Infarction (AMI or heart attack); Heart Failure; Pneumonia, and prevention of surgical infections. See our results on the Internet at http://www.hospitalcompare.hhs.gov/
- Cardiac Performance Improvement Project – this collaborative project includes ambulance staff, hospital staff and physicians, and cardiovascular staff and physicians at Good Samaritan Regional Medical Center (GSRMC). The team has evaluated transfer times from the coast to the cardiac center at GSRMC. Multiple actions were taken to reduce transfer times by 20%. The team is now focused on educational outreach to teach people to seek care much more quickly so heart muscle can be saved.
| Three Rivers Community Hospital |
Three Rivers Community Hospital Comments on Heart Failure: This AHRQ Quality Indicator represents the current state-of-the-art in assessing quality of care using hospital administrative data. However, this indicator must be used cautiously, because the administrative data on which the indicator is based is not collected for research purposes or for measuring quality of care, but for billing purposes. While these data are relatively inexpensive and convenient to use—and represent a rich data source that can provide valuable information—they should not be used as a definitive source of information on quality of health care. At least three limitations of administrative data warrant caution:
- Coding of information is different across hospitals. Some hospitals code more thoroughly than others, making “fair” comparisons across hospitals difficult.
- Ambiguity about when a condition occurs. Most administrative data cannot distinguish unambiguously whether a specific condition was present at admission or whether it occurred during the stay (i.e., a possible complication).
- The codes themselves are often not specific enough to adequately characterize a patient’s condition, which makes it impossible to perfectly risk-adjust any administrative data set, thus fair comparisons across hospitals become difficult.
The average age of residents in Josephine County is higher than the state average, and may be a contributing factor to the higher mortality. All in-hospital mortalities are reviewed for improvement purposes.
Comments last updated: June 30, 2005
Tuality Healthcare Comments on Heart Failure: Tuality Healthcare maintains an ongoing, strong commitment to Quality Improvement (QI) in patient care and other areas of operation. Tuality is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the College of American Pathologists (CAP). In compliance with JCAHO and CAP standards, Tuality continually monitors, collects and communicates numerous quality indicators. Tuality also fully complies with federal quality regulations established by the Centers for Medicare and Medicaid Services. In addition, Tuality openly participates in supplementary QI initiatives that help ensure positive patient outcomes, such as the “100,000 Lives Campaign” of the VHA and Institute for Health Care Quality.
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| Hip Fracture |
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| Mid Columbia Medical Center |
Mid Columbia Medical Center Comments on Hip Fracture: The quality of care provided to the patients at Mid-Columbia Medical Center is of utmost importance to us. If, as you review this information, you have any questions please contact the Performance and Quality Department by calling 541-296-7380 or by email at pqs@mcmc.net.
OHSU Comments on Hip Fracture: Oregon Health & Science University is Oregon’s only academic medical center. OHSU is a respected regional resource because of the knowledge, expertise and leading-edge medical technology that is available at OHSU Hospital, Doernbecher Children’s Hospital, and their numerous clinics and specialized centers. Doctors from throughout Oregon refer patients to OHSU when the necessary level of care or expertise is not available closer to home. Because OHSU is one of two designated Level 1 trauma centers in Oregon, OHSU accepts many patients who are critically ill or injured. OHSU only transfers patients who no longer require its unique services and can be tranferred to a hospital that is closer to their homes and can continue their care. www.OHSUhealth.com/ReportCards
What is hip fracture surgery?
A hip fracture is an acute condition in which the large thighbone breaks, often the result of a
fall. Hip fractures usually require immediate surgery to repair the broken bone with metal
hardware. Hip fracture patients are often elderly, so the condition of the patient and the
severity of the patient’s other medical conditions affect the risk associated with hip fracture
surgery.
OHSU expertise with hip fracture
Orthopaedic surgeons perform hip fracture surgery. Many doctors refer patients to OHSU
because of the level of expertise in caring for patients with more complex medical needs.
OHSU results
Patients admitted to OHSU for hip fracture in 2004 tended to have more severe underlying
diseases when compared to patients with hip fractures who were admitted to other Oregon
hospitals. Of the patients having hip fracture surgery at OHSU, 11% had been transferred to
OHSU from other hospitals. This is in comparison to 3.5% of patients requiring hip surgery
being transferred to other Oregon Hospitals.
OHSU results compared to other Oregon hospitals
After adjusting for the complexity of the underlying diseases, OHSU’s 3.6% death rate
following hip fracture was not significantly different than in other Oregon hospitals (3.3%).
| Providence Newberg Hospital |
Providence Newberg Hospital Comments on Hip Fracture: The 8.9% mortality rate reflects four patients who had serious medical problems and were not expected to live. The hip pinning/treatments were for comfort care only.
Comments last updated: June 24, 2005
| Sacred Heart Medical Center |
Sacred Heart Medical Center Comments on Hip Fracture: Sacred Heart Medical Center is committed to Transparency, which we define as being open and honest about the safety, quality, and level of patient satisfaction related to the care we provide as a means of fulfilling our promise to deliver exceptional medicine and compassionate care. http://www.peacehealth.org/AboutPH/OurPromise.htm.
Our providers, patients, and the communities we serve deserve to know how we're doing, because it's the right thing to do and because that's how we learn and improve. The link to Sacred Heart's transparency site can be found at http://www.peacehealth.org/apps/quality/QFacilityReport.asp?Hospital=2.
Public quality data on Sacred Heart performance can be found at a number of websites: the Joint Commission Hospital Quality Check website (http://www.jcaho.org/); the Center for Medicare and Medicaid Services Hospital Compare website (http://www.hospitalcompare.hhs.gov/); and the Oregon Pricepoint website (http://www.orpricepoint.org/). If you study these sites, you will find some differences in reported numbers. This is because each performance chart may use different time periods, different data sets, different specifications, and different risk adjustment methods. Finally, it bears repeating that these indicators must be used cautiously, because the administrative data on which the indicators are based are not collected for research purposes or for measuring quality of care, but for billing purposes. Nevertheless, this information can be used to launch explorations into reasons for potential quality problems, and that is exactly what Sacred Heart Medical Center does and takes seriously.
Sacred Heart Medical Center's Center for Healthcare Improvement has many personnel dedicated to reviewing and investigating all quality indicators from whatever source, and facilitating clinical improvements.
Comments last updated: July 8, 2005
| Three Rivers Community Hospital |
Three Rivers Community Hospital Comments on Hip Fracture: This AHRQ Quality Indicator represents the current state-of-the-art in assessing quality of care using hospital administrative data. However, this indicator must be used cautiously, because the administrative data on which the indicator is based is not collected for research purposes or for measuring quality of care, but for billing purposes. While these data are relatively inexpensive and convenient to use—and represent a rich data source that can provide valuable information—they should not be used as a definitive source of information on quality of health care. At least three limitations of administrative data warrant caution:
- Coding of information is different across hospitals. Some hospitals code more thoroughly than others, making “fair” comparisons across hospitals difficult.
- Ambiguity about when a condition occurs. Most administrative data cannot distinguish unambiguously whether a specific condition was present at admission or whether it occurred during the stay (i.e., a possible complication).
- The codes themselves are often not specific enough to adequately characterize a patient’s condition, which makes it impossible to perfectly risk-adjust any administrative data set, thus fair comparisons across hospitals become difficult.
The average age of residents in Josephine County is higher than the state average, and may be a contributing factor to the higher mortality. All in-hospital mortalities are reviewed for improvement purposes.
Comments last updated: June 30, 2005
Tuality Healthcare Comments on Hip Fracture: Tuality Healthcare maintains an ongoing, strong commitment to Quality Improvement (QI) in patient care and other areas of operation. Tuality is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the College of American Pathologists (CAP). In compliance with JCAHO and CAP standards, Tuality continually monitors, collects and communicates numerous quality indicators. Tuality also fully complies with federal quality regulations established by the Centers for Medicare and Medicaid Services. In addition, Tuality openly participates in supplementary QI initiatives that help ensure positive patient outcomes, such as the “100,000 Lives Campaign” of the VHA and Institute for Health Care Quality.
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| Pancreatic Resection |
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OHSU Comments on Pancreatic Resection: Oregon Health & Science University is Oregon’s only academic medical center. OHSU is a respected regional resource because of the knowledge, expertise and leading-edge medical technology that is available at OHSU Hospital, Doernbecher Children’s Hospital, and their numerous clinics and specialized centers. Doctors from throughout Oregon refer patients to OHSU when the necessary level of care or expertise is not available closer to home. Because OHSU is one of two designated Level 1 trauma centers in Oregon, OHSU accepts many patients who are critically ill or injured. OHSU only transfers patients who no longer require its unique services and can be tranferred to a hospital that is closer to their homes and can continue their care. www.OHSUhealth.com/ReportCards
What is pancreatic resection?
A pancreatic resection is a demanding and very specialized surgery to remove part of the
pancreas. The pancreas is located near the stomach. It is a vital part of the digestive system.
OHSU expertise with pancreatic resection
OHSU surgeons have the necessary skills to achieve outstanding outcomes for patients who
require surgery on their digestive systems. OHSU surgeons and clinical teams at OHSU
have specific expertise in pancreatic resections.
OHSU results
In 2004 surgeons at OHSU operated on 18 patients who needed pancreatic resections. This
was 29% of all pancreatic resections performed in Oregon. That number far exceeds the 11
procedures the State recommends as demonstrating experience with this type of surgery.
In 2004 none of the patients who had pancreatic resections at OHSU died during the post-
operative period. This is a 0% death rate.
OHSU results compared with other Oregon hospitals
OHSU’s results were far better than Oregon’s average death rate of 4.2% and the national
death rate of 7.7%.
| Sacred Heart Medical Center |
Sacred Heart Medical Center Comments on Pancreatic Resection: Sacred Heart Medical Center is committed to Transparency, which we define as being open and honest about the safety, quality, and level of patient satisfaction related to the care we provide as a means of fulfilling our promise to deliver exceptional medicine and compassionate care. http://www.peacehealth.org/AboutPH/OurPromise.htm.
Our providers, patients, and the communities we serve deserve to know how we're doing, because it's the right thing to do and because that's how we learn and improve. The link to Sacred Heart's transparency site can be found at http://www.peacehealth.org/apps/quality/QFacilityReport.asp?Hospital=2.
Public quality data on Sacred Heart performance can be found at a number of websites: the Joint Commission Hospital Quality Check website (http://www.jcaho.org/); the Center for Medicare and Medicaid Services Hospital Compare website (http://www.hospitalcompare.hhs.gov/); and the Oregon Pricepoint website (http://www.orpricepoint.org/). If you study these sites, you will find some differences in reported numbers. This is because each performance chart may use different time periods, different data sets, different specifications, and different risk adjustment methods. Finally, it bears repeating that these indicators must be used cautiously, because the administrative data on which the indicators are based are not collected for research purposes or for measuring quality of care, but for billing purposes. Nevertheless, this information can be used to launch explorations into reasons for potential quality problems, and that is exactly what Sacred Heart Medical Center does and takes seriously.
Sacred Heart Medical Center's Center for Healthcare Improvement has many personnel dedicated to reviewing and investigating all quality indicators from whatever source, and facilitating clinical improvements.
Comments last updated: July 8, 2005
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| Pediatric Heart Surgery |
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OHSU Comments on Pediatric Heart Surgery: Oregon Health & Science University is Oregon’s only academic medical center. OHSU is a respected regional resource because of the knowledge, expertise and leading-edge medical technology that is available at OHSU Hospital, Doernbecher Children’s Hospital, and their numerous clinics and specialized centers. Doctors from throughout Oregon refer patients to OHSU when the necessary level of care or expertise is not available closer to home. Because OHSU is one of two designated Level 1 trauma centers in Oregon, OHSU accepts many patients who are critically ill or injured. OHSU only transfers patients who no longer require its unique services and can be tranferred to a hospital that is closer to their homes and can continue their care. www.OHSUhealth.com/ReportCards
What is pediatric heart surgery?
Pediatric heart surgery includes many different types of surgeries on the hearts of infants and
children less than 18 years old. Sometimes doctors perform these surgeries to repair
conditions that have existed since birth. These conditions are called congenital birth defects.
OHSU expertise with pediatric heart surgery
Heart surgeons at OHSU are exceptionally skilled and operate on children with very
complex heart birth defects. Many of these complex surgeries are available at only a handful
of pediatric heart centers in the country. In Oregon, they are only available at Doernbecher
Children’s Hospital.
OHSU results
Physicians referred more than 170 children to OHSU and Doernbecher Children’s Hospital
for pediatric heart surgery in calendar year 2004. When OHSU’s results for these complex
patients are compared to other nationally recognized pediatric heart centers that have similar
patient populations, OHSU has among the lowest death rates in the United States.
OHSU results compared to other Oregon hospitals
Doernbecher Children’s Hospital is the only hospital in Oregon to perform many of these
complex surgeries.
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| Pneumonia |
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Coquille Valley Hospital Comments on Pneumonia: An intensive review of the specific cases reported as mortalities revealed that 2 of the 7 cases were "Do NOT resuscitate (DNR)" cases, which may have been for the most part "expected" as opposed to "unexpected" deaths upon admission. In addition, 3 of the remaining 5 cases demonstrated comorbid diagnosis (i.e. "secondary diagnosis") of advanced (stage IV), mediastinal metastatic lung disease (CA). Of the remaining 2 cases, both had associated comorbidities indicative of a "mediastinal mass or pleural-based tumor that could NOT be ruled out.
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Legacy Meridian Hospital Comments on Pneumonia:
Why is the pneumonia mortality rate higher at Legacy Meridian Park?
This is a good example of a non-quality related practice influencing a mortality rate. We have investigated this finding within the last year (as it was apparent on our own quality reporting system), and we determined that these deaths were in patients with other terminal illnesses who had been admitted to the hospital for comfort care. That is, their deaths were expected and there had been a determination that treating the pneumonia would only prolong their suffering. The higher death rate was therefore expected and did not reflect any lapses in the quality of care.
How is Legacy managing its quality processes?
Legacy staff regularly monitor mortality rates, along with many other indicators of care quality, in their efforts to provide the highest and safest care quality. Teams of physicians, nurses and administrators are constantly looking for new and better ways to reduce medication errors, infections, and other complications of the complex care processes provided in the hospital. Data such as these have long been part of that process and are viewed as an important part of our quality efforts.
| Mid Columbia Medical Center |
Mid Columbia Medical Center Comments on Pneumonia: The quality of care provided to the patients at Mid-Columbia Medical Center is of utmost importance to us. If, as you review this information, you have any questions please contact the Performance and Quality Department by calling 541-296-7380 or by email at pqs@mcmc.net.
OHSU Comments on Pneumonia: Oregon Health & Science University is Oregon’s only academic medical center. OHSU is a respected regional resource because of the knowledge, expertise and leading-edge medical technology that is available at OHSU Hospital, Doernbecher Children’s Hospital, and their numerous clinics and specialized centers. Doctors from throughout Oregon refer patients to OHSU when the necessary level of care or expertise is not available closer to home. Because OHSU is one of two designated Level 1 trauma centers in Oregon, OHSU accepts many patients who are critically ill or injured. OHSU only transfers patients who no longer require its unique services and can be tranferred to a hospital that is closer to their homes and can continue their care. www.OHSUhealth.com/ReportCards
What is pneumonia?
Pneumonia is a severe infection of the lung tissue that causes breathing problems. The
infection sometimes enters the bloodstream. When this happens, the infection spreads
throughout the body and the patient goes into shock. Doctors treat patients with pneumonia
by carefully selecting antibiotic medications and using special equipment to help the patient
breathe.
OHSU expertise with pneumonia
OHSU specialists are highly skilled in treating pneumonia.
OHSU results compared with other Oregon hospitals
In 2004 patients admitted to OHSU Hospital for pneumonia had a lower death rate (6.1%)
than the average death rate of patients admitted to other Oregon hospitals (7.1%).
| Sacred Heart Medical Center |
Sacred Heart Medical Center Comments on Pneumonia: Sacred Heart Medical Center is committed to Transparency, which we define as being open and honest about the safety, quality, and level of patient satisfaction related to the care we provide as a means of fulfilling our promise to deliver exceptional medicine and compassionate care. http://www.peacehealth.org/AboutPH/OurPromise.htm.
Our providers, patients, and the communities we serve deserve to know how we're doing, because it's the right thing to do and because that's how we learn and improve. The link to Sacred Heart's transparency site can be found at http://www.peacehealth.org/apps/quality/QFacilityReport.asp?Hospital=2.
Public quality data on Sacred Heart performance can be found at a number of websites: the Joint Commission Hospital Quality Check website (http://www.jcaho.org/); the Center for Medicare and Medicaid Services Hospital Compare website (http://www.hospitalcompare.hhs.gov/); and the Oregon Pricepoint website (http://www.orpricepoint.org/). If you study these sites, you will find some differences in reported numbers. This is because each performance chart may use different time periods, different data sets, different specifications, and different risk adjustment methods. Finally, it bears repeating that these indicators must be used cautiously, because the administrative data on which the indicators are based are not collected for research purposes or for measuring quality of care, but for billing purposes. Nevertheless, this information can be used to launch explorations into reasons for potential quality problems, and that is exactly what Sacred Heart Medical Center does and takes seriously.
Sacred Heart Medical Center's Center for Healthcare Improvement has many personnel dedicated to reviewing and investigating all quality indicators from whatever source, and facilitating clinical improvements.
Comments last updated: July 8, 2005
| Samaritan North Lincoln Hospital |
Samaritan North Lincoln Hospital Comments on Pneumonia: Rural hospitals do not have the same volume of patients as hospitals in larger communities, so it is difficult to make meaningful comparisons between the two. Patients requiring a higher level of care are transferred to a larger facility, further decreasing the volume for comparison for these indicators.
- The population of Lincoln County contains a higher percentage than most counties in the state of people 65 and older. These people are more likely to suffer from cardiac & vascular problems as well as cancer, diabetes and other chronic diseases.
- People in the last stages of their illness often request comfort care in the local hospital setting. This supports patients and their families in death with dignity.
- Quality initiatives and performance improvement projects are ongoing in our facilities. At any given time there are typically over 100 initiatives underway. Some of these include:
- National Patient Safety Goals – We support these with specific action plans and by auditing our progress.
- Core Measures – We participate in this national voluntary public reporting project. We track and report certain measures for patients with Acute Myocardial Infarction (AMI or heart attack); Heart Failure; Pneumonia, and prevention of surgical infections. See our results on the Internet at http://www.hospitalcompare.hhs.gov/
- Cardiac Performance Improvement Project – this collaborative project includes ambulance staff, hospital staff and physicians, and cardiovascular staff and physicians at Good Samaritan Regional Medical Center (GSRMC). The team has evaluated transfer times from the coast to the cardiac center at GSRMC. Multiple actions were taken to reduce transfer times by 20%. The team is now focused on educational outreach to teach people to seek care much more quickly so heart muscle can be saved.
| Southern Coos Hospital and Health Center |
Southern Coos Hospital and Health Center Comments on Pneumonia: We are a small rural facility in a retirement community. In our sampled population the average age was 81 years. The average mortality risk was a 4. The average number of diagnostic codes was 4. The raw statistics do not reflect this skewed data. We feel this data cannot be compared generally unless all other statistics reflect similar or comparable demographic and co-morbid conditions.
Many of our patients came in with POLST forms or advance directives already in place indicating that they were not to be resuscitated or did not want extensive life saving measures.
Our concern is that the average consumer, looking at these statistics, may infer our care is substandard because our death rate is higher than expected.
| Three Rivers Community Hospital |
Three Rivers Community Hospital Comments on Pneumonia: This AHRQ Quality Indicator represents the current state-of-the-art in assessing quality of care using hospital administrative data. However, this indicator must be used cautiously, because the administrative data on which the indicator is based is not collected for research purposes or for measuring quality of care, but for billing purposes. While these data are relatively inexpensive and convenient to use—and represent a rich data source that can provide valuable information—they should not be used as a definitive source of information on quality of health care. At least three limitations of administrative data warrant caution:
- Coding of information is different across hospitals. Some hospitals code more thoroughly than others, making “fair” comparisons across hospitals difficult.
- Ambiguity about when a condition occurs. Most administrative data cannot distinguish unambiguously whether a specific condition was present at admission or whether it occurred during the stay (i.e., a possible complication).
- The codes themselves are often not specific enough to adequately characterize a patient’s condition, which makes it impossible to perfectly risk-adjust any administrative data set, thus fair comparisons across hospitals become difficult.
The average age of residents in Josephine County is higher than the state average, and may be a contributing factor to the higher mortality. All in-hospital mortalities are reviewed for improvement purposes.
Comments last updated: June 30, 2005
Tuality Healthcare Comments on Pneumonia: Tuality Healthcare maintains an ongoing, strong commitment to Quality Improvement (QI) in patient care and other areas of operation. Tuality is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the College of American Pathologists (CAP). In compliance with JCAHO and CAP standards, Tuality continually monitors, collects and communicates numerous quality indicators. Tuality also fully complies with federal quality regulations established by the Centers for Medicare and Medicaid Services. In addition, Tuality openly participates in supplementary QI initiatives that help ensure positive patient outcomes, such as the “100,000 Lives Campaign” of the VHA and Institute for Health Care Quality.
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| Stroke |
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Legacy Emanuel Hospital Comments on Stroke:
How is Legacy managing its quality processes?
Legacy staff regularly monitor mortality rates, along with many other indicators of care quality, in their efforts to provide the highest and safest care quality. Teams of physicians, nurses and administrators are constantly looking for new and better ways to reduce medication errors, infections, and other complications of the complex care processes provided in the hospital. Data such as these have long been part of that process and are viewed as an important part of our quality efforts.
How good a measure of quality is mortality? Reported mortality rates for hospitals represent a complex mix of factors. Most importantly, it has been shown that patient factors, such as severity of illness or pre-existing conditions, such as diabetes or heart failure, are the most powerful predictor of mortality rates. Often, institutions vary widely in what kind of patients they see and what patients are selected to undergo various treatments. A large, complex institution will tend to see sicker, more complex patients, as a rule. Thus, mortality rates for surgical procedures are often higher in tertiary care facilities. This is called patient selection bias. Severity adjustment tools help correct for this kind of bias, but they are inexact. There are a variety of risk adjustment tools in existence, and we have seen as much as a 2-fold difference in expected mortality rates, depending on which risk adjustment tool is used.
| Mid Columbia Medical Center |
Mid Columbia Medical Center Comments on Stroke: The quality of care provided to the patients at Mid-Columbia Medical Center is of utmost importance to us. If, as you review this information, you have any questions please contact the Performance and Quality Department by calling 541-296-7380 or by email at pqs@mcmc.net.
OHSU Comments on Stroke: Oregon Health & Science University is Oregon’s only academic medical center. OHSU is a respected regional resource because of the knowledge, expertise and leading-edge medical technology that is available at OHSU Hospital, Doernbecher Children’s Hospital, and their numerous clinics and specialized centers. Doctors from throughout Oregon refer patients to OHSU when the necessary level of care or expertise is not available closer to home. Because OHSU is one of two designated Level 1 trauma centers in Oregon, OHSU accepts many patients who are critically ill or injured. OHSU only transfers patients who no longer require its unique services and can be tranferred to a hospital that is closer to their homes and can continue their care. www.OHSUhealth.com/ReportCards
What is a stroke?
A stroke occurs when an artery that supplies blood to the brain becomes blocked or
ruptures and brain cells (known as neurons) die. A stroke is an acute medical problem.
Symptoms may include paralysis, and difficulty with speech, vision, hearing and/or touch.
Sometimes these symptoms are permanent and sometimes they partially improve with time.
OHSU expertise with stroke
OHSU operates the Oregon Stroke Center and has made a special commitment to
improving the outcomes of patients who have had strokes. Many Oregon hospitals transfer
their serious stroke patients to OHSU because of this level of expertise. Therefore, OHSU’s
stroke patients tend to be more severely ill or have more complicated overall medical
conditions than patients who are admitted to other Oregon hospitals.
OHSU results
In 2004 OHSU provided care to 6% of all stroke patients in Oregon.
OHSU results compared with other Oregon hospitals
After adjusting for the severity of their overall medical condition, OHSU stroke patients had
a significantly lower death rate (9.5%) as compared to the 12.7% death rate for stroke
patients admitted to other Oregon hospitals in 2004.
| Sacred Heart Medical Center |
Sacred Heart Medical Center Comments on Stroke: Sacred Heart Medical Center (SHMC) has actively worked on improving stroke care since 1996, thanks to the efforts of dedicated physician and nursing leaders, and has a Neurological/Rehabilitation Clinical Service interdisciplinary group that meets monthly to review and make recommendations for improvements in a variety of neurological disorders including stroke. SHMC has participated over the years in state and national collaborative efforts to improve stroke care, by submitting data on various aspects of stroke care and their effect on outcomes such as mortality rate.
It came as a surprise in the latest statewide and national collaborative to discover that Oregon has the third worst stroke death rate in the nation, and that SHMC’s stroke death rate was higher than the state average. While there are many complex reasons for this (including Oregon’s cultural attitudes to end-of-life care, use of advanced directives and do not resuscitate instructions, time required to travel to the hospital after onset of symptoms, etc); an interdisciplinary team of neurologists, neurosurgeons, vascular surgeons, hospitalists, emergency physicians, radiologists, rehabilitation physicians, nursing staff, and administrative staff was convened to review SHMC’s stroke care and made recommendations for improvement. This has resulted in improvements in time to imaging on arrival at hospital; quicker time to thrombolytic therapy when appropriate; recommendation to become certified as a Stroke Center of Excellence/Primary Stroke Center; and a significant community education and screening program as part of our community’s Know Stroke campaign (http://www.knowstroke.org/).
SHMC maintains an active program to review the outcomes of care provided to its patients; and philosophically believes that being open and honest – transparent – about the care received by its patients, ultimately leads to ongoing improvements in care. To view SHMC’s Transparency Website demonstrating the results of care provided at SHMC and what we are doing about it, please visit http://www.peacehealth.org/apps/quality/QFacilityReport.asp?Hospital=2
Comments last updated: July 8, 2005
| Samaritan Pacific Communities Hospital |
Samaritan Pacific Communities Hospital Comments on Stroke: Rural hospitals do not have the same volume of patients as hospitals in larger communities, so it is difficult to make meaningful comparisons between the two. Patients requiring a higher level of care are transferred to a larger facility, further decreasing the volume for comparison for these indicators.
- The population of Lincoln County contains a higher percentage than most counties in Oregon of people 65 and older. These people are more likely to suffer from cardiac & vascular problems as well as cancer, diabetes and other chronic diseases.
- People in the last stages of their illness often request comfort care in the local hospital setting. This supports patients and their families in death with dignity.
- Quality initiatives and performance improvement projects are ongoing in our facilities. At any given time there are typically over 100 initiatives underway. Some of these include:
- National Patient Safety Goals – We support these with specific action plans and by auditing our progress.
- Core Measures – We participate in this national voluntary public reporting project. We track and report certain measures for patients with Acute Myocardial Infarction (AMI or heart attack); Heart Failure; Pneumonia, and prevention of surgical infections. See our results on the Internet at http://www.hospitalcompare.hhs.gov/
- Cardiac Performance Improvement Project – this collaborative project includes ambulance staff, hospital staff and physicians, and cardiovascular staff and physicians at Good Samaritan Regional Medical Center (GSRMC). The team has evaluated transfer times from the coast to the cardiac center at GSRMC. Multiple actions were taken to reduce transfer times by 20%. The team is now focused on educational outreach to teach people to seek care much more quickly so heart muscle can be saved.
Tuality Healthcare Comments on Stroke: Tuality Healthcare maintains an ongoing, strong commitment to Quality Improvement (QI) in patient care and other areas of operation. Tuality is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the College of American Pathologists (CAP). In compliance with JCAHO and CAP standards, Tuality continually monitors, collects and communicates numerous quality indicators. Tuality also fully complies with federal quality regulations established by the Centers for Medicare and Medicaid Services. In addition, Tuality openly participates in supplementary QI initiatives that help ensure positive patient outcomes, such as the “100,000 Lives Campaign” of the VHA and Institute for Health Care Quality.
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