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RSFH's Compliance with CMS/Core Quality Measures

Reporting Leads to Improvement
Roper St. Francis Healthcare is dedicated to improving patient care. We believe you can't improve what you don't measure. That is why we have committed to measuring and publicly reporting our performance.

Quality Measurement
There are scientific ways to measure health care quality and are used by health professionals to review and improve the quality of care they provide. A quality measure is information from a patient's record or an operational process converted into a rate, percentage, or time showing how well providers are taking care of their patients. Quality measures provide information on how well providers care for some, but not all of their patients. Most quality measures have been designed to measure evidence-based care. Patients who should not get the recommended care treatments are not counted in the measures.

Quality measurement is a relatively new science and requires a large amount of resources to develop and collect the information. Fully developed and tested measures are only available for reporting on some of the most common conditions or processes of care. The data listed below is the current comparison data available from Centers for Medicare/Medicaid Services (CMS) based on the quality metrics requested for public reporting. More information can be found at www.myschospital.org and/or www.hospitalcompare.hhs.gov.

 

Measurement Data

from 01/01/2008-12/31/2008

Data from the CMS' Hospital Compare website
Report generated Oct 2, 2009  pmb

 
 Heart Attack Roper
St. Francis State Ave.
Nati. Ave.
Aspirin at arrival 99% + 97% 94%
Aspirin at discharge 98% + 93% 93%
Beta-blocker at discharge 100% + 93% 93%
ACEI for LVSD 100% + 96% 90%
Smoking Cessation Counseling 100% + 99% 95%
PCI rec within 90 min of arrival 95% - 90% 77%
 
 Heart Failure Roper
St. Francis State Ave.
Nati. Ave.
LVF assessment (%) 100% 100% 95% 89%
ACEI for LVSD (%) 98% 100% 92% 89%
Smoking Cessation Counseling 100% 100% 94% 91%
Discharge Instructions (%) 77% 71% 80% 76%

 Pneumonia Roper
St. Francis State Ave.
Nati. Ave.
Pneumococcal vaccination (%) 88% 94% 89% 84%
Smoking Cessation Counseling (%) 100% 100% 95% 89%
Less than 6 hours to antibiotics (%) 96% 93% 94% 93%
Approp Anbtc 89% 83% 88% 87%
Blood Cultr 97% 95% 93% 91%
Flu vaccine 88% 100% 89% 82%

 

 
 Surgical Infection Prevention Roper
St. Francis State Ave.
Nati. Ave.
Antibiotics within 1hr Surgery (%) 97% 100% 92% 89%
Antibiotics Selection (%) 98% 100% 92% 94%
Antibiotics DC'd within 24hrs (%) 95% 98% 90% 87%
Cardiac Patients with Controlled Blood Glucose (%) 91% - 86% 85%
Appropriate Hair Removal (%) 98% 98% 97% 96%
VTE Prophylaxis (%) 95% 96% 89% 87%
VTE Prophylaxis Timing (%) 94% 96% 88% 84%

 

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