Hospital Performance Report, 2009 (PDF)
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A Message . From the Commissioner For questions about this report, please contact: Office of the Commissioner Health Care Quality Assessment (HCQA) Dear Consumers: New Jersey Department of Health and Senior Services P.O. Box 360, Trenton, New Jersey 08625-0360 New Jersey is a national leader in public reporting on health care quality and the Department of Health and Senior Services remains You can also reach HCQA by phone at (800) 418-1397. committed to continuing to improve patient safety and providing the highest quality care for all of the residents of New Jersey. Find more information on our web site at The sixth annual report on hospital quality, the New Jersey 2009 www.nj.gov/health/hpr. The site allows you to choose Hospital Performance Report includes two additional measures for hospitals to compare by hospital name, condition or surgical care infection prevention in addition to performance county. In addition to the recommended care measures measures for heart attack, pneumonia, and congestive heart failure. and Patient Safety Indicators (PSI) included in this report, The report also includes 12 new measures for patient safety, as the web site also includes mortality measures for required by Senate Bill No. 2471. The new measures show how coronary artery bypass graft (CABG) surgery, heart attack, well hospitals are doing preventing specific medical errors. pneumonia, heart failure, and stroke. The web site also contains an extensive list of resources and patient safety The purpose of the report is to increase public awareness of quality tips on how to prevent medical errors. issues and to promote quality care in New Jersey hospitals by publicly reporting individual hospital performances. The consumer information provided in this report—including tips on safer surgery Portions of this report rely on material developed by the and how to choose a hospital or doctor—is intended to help US Department of Health and Human Services, Centers patients and their families become more active participants in their for Medicare and Medicaid Services, the Agency for own health care decisions. The report is also intended to Healthcare Research and Quality, and the Joint encourage healthy competition among hospitals and motivate their Commission. leaders to improve the quality of care for the patients they serve. I would like to thank the members of the Quality Improvement Other reports produced by HCQA and found at the Advisory Committee (QIAC), who have been an invaluable asset to web site: the Department in developing this report and other Department Cardiac Surgery in New Jersey quality initiatives. QIAC members consist of leaders from the New Inpatient Quality Indicators Jersey hospital industry, insurers, payers, universities as well as Bariatric Surgery in New Jersey physicians, nurses and consumers. Prevention Quality Indicators I encourage you to visit our newly redesigned web site at Patient Safety Indicators www.nj.gov/health/hpr. It contains more information than the report, is interactive, and more user-friendly. Please feel free to send us your feedback on the report or the web site at [email protected]. Heather Howard Commissioner Department of Health and Senior Services A Consumer Report 53 Table of Contents Section 1: Using This Report D Hospital Quality and Using This Report . 4 How to use this report D Importance of These Measures. 6 Why were these measures chosen? Section 2: Recommended Care/Process of Care Measures D Overall Scores . 8 Heart Attack, Pneumonia, Surgical Care Improvement and Heart Failure D Heart Attack Treatment Scores . 10 Overall Heart Attack Score Aspirin at Arrival Aspirin at Discharge Beta Blocker at Arrival Beta Blocker at Discharge ACE Inhibitor or ARB at Discharge Smoking Cessation Advice PCI Within 90 Minutes D Basic Facts on Treating Heart Attacks. 12 Treatment measures and health care information D Pneumonia Treatment Scores. 14 Overall Pneumonia Score Oxygenation Assessment Pneumonia Vaccination Influenza Vaccination Antibiotic Timing Antibiotic Selection Blood Culture before Initial Antibiotic Smoking Cessation Advice D Basic Facts on Treating Pneumonia . 16 Treatment measures and health care information D Surgical Care Improvement Scores . 18 Overall Surgical Care Score Preventive Antibiotic Started Preventive Antibiotic Stopped Appropriate Antibiotic Received Treatment Preventing Blood Clots Ordered Treatment Preventing Blood Clots Received Controlled Blood Sugar for Heart Patients Safe Hair Removal Table of Contents D Basic Facts on Surgical Care Improvement . 20 Treatment measures and health care information D Heart Failure Treatment Scores. 22 Overall Heart Failure Score Left Ventricular Systolic Function Assessment ACE Inhibitor or ARB at Discharge Discharge Instructions Smoking Cessation Advice D Basic Facts on Treating Heart Failure . 24 Treatment measures and health care information Section 3: Patient Safety Indicators (PSIs) D PSI Data . 26 D Basic Facts on Patient Safety Indicators . 30 Section 4: Consumer Information D Taking an Active Role in Your Health Care . 36 Patient responsibilities for maintaining health and understanding treatment options D Patient Safety Tips for Surgery. 38 Questions to ask before surgery D Finding a Doctor or Information on a Doctor . 39 What to look for in a doctor and web sites to find one D Health Information and Referral . 40 Health care resources D Hospital Patients…KnowYour Rights. 42 Patient rights in New Jersey D Hospital Quality Oversight . 44 Government regulatory supervision D Filing a Complaint . 45 How to file a hospital complaint D Quality Improvement Advisory Committee . 46 Section 5:Appendix D New Jersey General Acute Care Hospitals . 48 2 Hospital Performance Report 2009 1 n o i t c e Section 1 S Using This Report D Hospital Quality and Using This Report D Importance of These Measures Hospital Quality& Using This Report he New Jersey Hospital Performance The data for the recommended care in this report is for Report was created to provide hospital the year 2008. quality information to patients, their families, and health care professionals. The For the first time, the report also includes how well each information is designed to help you choose a hospital is providing safe patient care by looking at the Thospital and make other decisions about your health. number of medical errors per hospital that could have been avoided. These are called patient safety The report shows how each hospital treats eligible indicators (PSIs). The PSIs were developed nationally patients with heart attack, pneumonia, heart failure and after extensive research and analysis. The data for PSIs patients having surgery. Patients must receive in this report is for the year 2007. the correct care in order to fully recover. These measures, which are based on recognized national Please refer to the Technical Report at www.nj.gov/ standards for diagnosis and treatment, are called health/hpr for more detail and for calculations. recommended care or process of care measures. What do the hospital scores mean? All recommended care tables include the Top 10% and Top 50% performers for RECOMMENDED CARE (PROCESS OF CARE) each measure. These scores help MEASURES determine which hospitals are among the top 10% or 50% of NJ hospitals for the The score for each recommended care specific measure. If your hospital has a measure reflects the percentage of score that is equal to or greater than the eligible patients who received the score displayed at the top of the table, it recommended treatment. For example, is among the top 10% or 50% performers a score of 85% means that the hospital in NJ on the specific measure. provided the recommended care for 85 out of 100 patients eligible for the PATIENT SAFETY INDICATORS (PSIs) recommended care. The goal for each hospital is 100% so that all eligible For the PSIs, the score for each patients receive the best care. Patients measure is not a percentage. The scores who should not receive the treatments reflect how well a hospital is doing in due to their specific conditions are preventing medical errors from Lower excluded from the measures. Please occurring in each hospital. scores are better; lower scores mean note that small differences in hospital that there were fewer medical errors scores do not indicate real differences in for that particular medical condition at hospital quality. that hospital. The report includes four Overall Scores See pages 26 –29 for the PSI data and for how each hospital treats patients pages 30–34 for basic facts on PSIs. diagnosed with heart attack, pneumonia, heart failure and patients having Which hospitals are included? surgery. An Overall Score is a summary of all the scores for the individual All New Jersey general acute care measures for a specific condition. The hospitals are included, along with one Overall Scores are shown on pages 8 specialty hospital that treats heart and 9. Scores for individual measures disease. Because of the different years are provided on the pages following the in data, PSIs include one additional Overall Scores. hospital that was open in 2007 but closed in 2008. 4 Hospital Performance Report 2009 Section 1 Using This Report How is the information collected? Aren’t all doctors and hospitals the same? For recommended care (process of care) measures, the information is collected No. Hospitals differ in their specialties by hospitals from patient medical and expertise. Some are better records. This review shows whether a equipped than others to handle patient received the correct care. The different conditions and levels of care. Centers for Medicare and Medicaid Not all hospitals have state approval to Services (CMS) reviews the consistency perform certain services. Hospitals of each hospital’s data. All New Jersey employ doctors with different hospitals’ data passed this review. To specialties, expertise and abilities. learn more about the data collection These differences will influence the methods and the CMS audit process, see quality of care that you receive.