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APPENDIX H Professional Practice Evaluation Credentialing Report

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APPENDIX H Professional Practice Evaluation Credentialing Report APPENDIX H Professional Practice Evaluation Credentialing Report Provider: Facility: Comparison Group: -Surgery-General Surgery Report Period: Last 24 months (06/01/2009 - 05/31/2011)07/28/2011 Report Date: 07/28/2011 Volumes Volume (Group Volume) Admit Attending Consult Emergency Surgeon Inpatient 319 (1,293) 339 (1,305) 58 (251) 0 (13) 328 (1,214) Outpatient - SDS, High Risk Procedures 1,721 (4,932) 1,722 (4,931) 9 (30) 3 (9) 1,726 (4,933) Outpatient - Observation 11 (29) 12 (26) 0 (4) 0 (0) 6 (9) Emergency-Casemix 0 (11) 1 (5) 10 (54) 0 (3) 4 (8) Emergency-Charge Code 187 (826) 201 (817) 38 (206) 2 (25) 184 (726) Hospital Clinic 228 (1,168) CaseMix/Utilization Provider Provider Comparison Comparison Measure Cases Measure Cases Case Mix Index - Total Inpatient 1.6 339 1.4 1,305 Case Mix Index - Outpatient 0.6 1,734 0.8 4,957 % of Discharges with Severity of Illness - Minor 43.4% 339 40.3% 1,304 % of Discharges with Severity of Illness - Moderate 37.2% 339 42.2% 1,304 % of Discharges with Severity of Illness - Major 13.9% 339 13.1% 1,304 % of Discharges with Severity of Illness - Extreme 5.6% 339 4.4% 1,304 Average Inpatient Length of Stay by Severity of Illness - Minor 3.6 147 2.5 526 Average Inpatient Length of Stay by Severity of Illness - Moderate 4.5 126 3.7 550 Average Inpatient Length of Stay by Severity of Illness - Major 7.6 47 5.9 171 Average Inpatient Length of Stay by Severity of Illness - Extreme 12.2 19 12.6 57 Mortality Provider Provider Comparison Comparison Measure Cases Measure Cases Acute Inpatient Mortality 0.6% 339 0.6% 1,266 Total Inpatient Mortality 0.6% 339 1.9% 1,305 Mortality Rate by Risk of Mortality - Minor 0.0% 239 0.1% 925 Mortality Rate by Risk of Mortality - Moderate 0.0% 63 4.0% 249 Mortality Rate by Risk of Mortality - Major 0.0% 22 8.1% 86 Mortality Rate by Risk of Mortality - Extreme 13.3% 15 15.9% 44 % of Discharges with Risk of Mortality - Minor 70.5% 339 70.9% 1,304 % of Discharges with Risk of Mortality - Moderate 18.6% 339 19.1% 1,304 % of Discharges with Risk of Mortality - Major 6.5% 339 6.6% 1,304 % of Discharges with Risk of Mortality - Extreme 4.4% 339 3.4% 1,304 Pneumonia Core Measures Provider Provider Comparison Comparison Measure Cases Measure Cases PN-2: Pneumococcal Screening and/or Vaccination 100.0% 1 0.0% 0 CONFIDENTIAL: This material is prepared pursuant to Utah Code Ann. ' 26-25-1 et seq., Idaho Code Ann. ' Page 1 of 10 Run Date: 07/28/11 1:07 PM 39-1392 et seq., for improvement of the quality of hospital and medical care rendered by hospitals or physicians Report Author: Created: 05/03/10 9:15 AM and is NOT PART of the medical record, should not be kept in or with the medical record, and should not be copied. MetaReport NAMSS Credentialing 101 APPENDIX H Professional Practice Evaluation Credentialing Report Provider: Facility: Comparison Group: -Surgery-General Surgery Report Period: Last 24 months (06/01/2009 - 05/31/2011)07/28/2011 Report Date: 07/28/2011 Surgical Care Improvement Core Measures Provider Provider Comparison Comparison Measure Cases Measure Cases SCIP-1a: Prophylactic antibiotic received within one hour prior to surgical incision 95.7% 23 97.1% 70 - overall rate SCIP-2a: Prophylactic antibiotic selection for surgical patients - overall rate 95.7% 23 98.6% 71 SCIP-3a: Prophylactic antibiotics discontinued within 24 hours after surgery end 100.0% 22 95.3% 64 time - overall rate SCIP-6: Surgery Patients with Appropriate Hair Removal 100.0% 47 100.0% 155 SCIP-7: Colorectal Surgery Patients with Immediate Postoperative Normothermia 50.0% 2 76.9% 13 SCIP-9: Surgical patients with urinary catheter removed on Postoperative Day 1 or 64.7% 17 93.8% 48 Postoperative Day SCIP-10: Surgery Patients with Perioperative Temperature Management 100.0% 45 100.0% 136 SCIP-Card-2: Surgery Patients on Beta Blocker Therapy Prior to Admission Who 77.8% 9 72.2% 18 Received a Beta Blocker During the Perioperative Period SCIP-VTE-1: Surgery Patients with Recommmended Vernous Thromboembolism 37.0% 27 84.9% 86 Prophylaxis Ordered SCIP-VTE-2: Surgery Patients Who Received Appropirate Venous 37.0% 27 82.6% 86 Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery Hospital Outpatient Core Measures Provider Provider Comparison Comparison Measure Cases Measure Cases OP-6:Prophylactic Antibiotic Initiated w/in One Hour Prior to Surgical Incision 0.0% 0 100.0% 1 OP-7:Prophylactic Antibiotic Selection for Surgical Patients 0.0% 0 0.0% 1 Satisfaction Provider Provider Comparison Comparison Measure Cases Measure Cases How often did the doctor explain things in a way you could understand? (% 85.3% 102 78.7% 414 Always - HCAHPS) How often did the doctor treat you with courtesy and respect (% Always - 95.1% 103 88.4% 414 HCAHPS) How often did the doctor listen carefully to you? (% Always - HCAHPS) 82.5% 103 82.3% 413 The genuine caring and concern shown to you by the physician. (% Excellent) 81.6% 212 77.1% 1,016 The skills and knowledge of the physician. (% Excellent) 91.0% 212 83.7% 1,007 How well the physician explained things to you. (% Excellent) 76.7% 120 70.5% 650 CONFIDENTIAL: This material is prepared pursuant to Utah Code Ann. ' 26-25-1 et seq., Idaho Code Ann. ' Page 2 of 10 Run Date: 07/28/11 1:07 PM 39-1392 et seq., for improvement of the quality of hospital and medical care rendered by hospitals or physicians Report Author: Created: 05/03/10 9:15 AM and is NOT PART of the medical record, should not be kept in or with the medical record, and should not be copied. MetaReport NAMSS Credentialing 101 APPENDIX HN Professional Practice Evaluation Credentialing Report Provider: Facility: Comparison Group: -Surgery-General Surgery Report Period: Last 24 months (06/01/2009 - 05/31/2011)07/28/2011 Report Date: 07/28/2011 Peer Review Provider Provider Comparison Comparison Measure Cases Measure Cases Peer Review - Total 02 Peer Review - Appropriate 0.0% 0 0.0% 2 Peer Review - Inappropriate 0.0% 0 50.0% 2 Peer Review - Controversial 0.0% 0 0.0% 2 Peer Review - Questionable 0.0% 0 50.0% 2 Medical Records Compliance Provider Provider Comparison Comparison Measure Cases Measure Cases History and Physical Delinquency 4.2% 502 12.0% 1,262 Post Procedure Dictation 2.7% 592 7.6% 865 Total Chart Delinquency 3.2% 436 11.8% 1,155 Facility Specific Measures Provider Provider Comparison Comparison Measure Cases Measure Cases Pediatric Inpt Dsch3: (Ages >=14 Years and <18 Years) 315 Postoperative PE or DVT (Modified AHRQ Outcome Measure) 1.1% 262 0.7% 1,002 Unplanned Readmission Within 30 Days 2.9% 314 3.1% 1,194 Unplanned Return to OR within 30 Days 1.0% 1,845 1.4% 5,562 CONFIDENTIAL: This material is prepared pursuant to Utah Code Ann. ' 26-25-1 et seq., Idaho Code Ann. ' Page 3 of 10 Run Date: 07/28/11 1:07 PM 39-1392 et seq., for improvement of the quality of hospital and medical care rendered by hospitals or physicians Report Author: Created: 05/03/10 9:15 AM and is NOT PART of the medical record, should not be kept in or with the medical record, and should not be copied. MetaReport NAMSS Credentialing 101 APPENDIX H Professional Practice Evaluation Credentialing Report Provider: Facility: Comparison Group: -Surgery-General Surgery Report Period: Last 24 months (06/01/2009 - 05/31/2011)07/28/2011 Report Date: 07/28/2011 Volumes by APRDRG128 APRDRG Code APRDRG Description Total Inpatient Outpatient 861 Signs, symptoms & other factors influencing health status 389 389 254 Other digestive system diagnoses 247 3 244 263 Laparoscopic cholecystectomy 228 31 197 228 Inguinal, femoral & umbilical hernia procedures 153 1 152 862 Other aftercare & convalescence 135 135 220 Major stomach, esophageal & duodenal procedures 129 51 78 251 Abdominal pain 109 4 105 221 Major small & large bowel procedures 100 96 4 227 Hernia procedures except inguinal, femoral & umbilical 99 7 92 225 Appendectomy 69 17 52 243 Other esophageal disorders 57 2 55 226 Anal procedures 36 2 34 247 Intestinal obstruction 27 23 4 241 Peptic ulcer & gastritis 23 2 21 249 Non-bacterial gastroenteritis, nausea & vomiting 19 2 17 364 Other skin, subcutaneous tissue & related procedures 17 17 222 Other stomach, esophageal & duodenal procedures 16 4 12 223 Other small & large bowel procedures 12 8 4 363 Breast procedures except mastectomy 11 11 663 Other anemia & disorders of blood & blood-forming organs 11 1 10 224 Peritoneal adhesiolysis 10 5 5 260 Major pancreas, liver & shunt procedures 10 9 1 404 Thyroid, parathyroid & thyroglossal procedures 10 10 253 Other & unspecified gastrointestinal hemorrhage 918 229 Other digestive system & abdominal procedures 817 813 Other complications of treatment 826 244 Diverticulitis & diverticulosis 743 252 Malfunction, reaction & complication of gi device or procedure 752 681 Other o.r. procedures for lymphatic/hematopoietic/other neoplasms 6 6 951 Moderately extensive procedure unrelated to principal diagnosis 633 245 Inflammatory bowel disease 5 5 651 Other procedures of blood & blood-forming organs 5 5 710 Infectious & parasitic diseases including hiv w o.r. procedure 55 791 O.r. procedure for other complications of treatment 55 180 Other circulatory system procedures 4 4 240 Digestive malignancy 4 4 362 Mastectomy procedures 413 385 Other skin, subcutaneous tissue & breast disorders 4 4 401 Pituitary & adrenal procedures 422 680 Major o.r.
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