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The presentation will begin shortly.
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AnMed Health Disparities DashboardKeeping it
REaL An Analysis of Health Care Quality Among
Priority Patient Populations

• Juana Slade, CDM, CCF
• Director, Diversity and Language Services
• Suzanne Wilson, RN, MBA
• Director, Medical Resource Management
• Presented in partnership with the
• Institute for Diversity in Health Management
• Health Research Education Trust
• Affiliates of the American Hospital Association
• May 30, 2012

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AnMed Health

• 578 Bed Acute Care System
• 461 AnMed Health Medical Center
• 72 AnMed Health Womens and Children's Hospital
• 45 AnMed Health Rehabilitation Hospital
• 24,054 Inpatient admissions
• 205,400 Outpatient procedures
• 107,818 ED visits
• 400 Admitting physicians
• 2800 Employees

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to passionately blend the art of caring with the
science of medicine to optimize the health of our
patients, staff and community.
Our Mission
Our Vision
to be recognized and celebrated as the gold
standard for healthcare quality and community
health improvement.
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Gold Standard Celebrations
The Joint Commissions Stroke Center of Excellence
The Joint Commissions Top Performer on Key
Quality Measures
IHI Mentor Hospital for Acute Myocardial
Infarction
Healthgrades Clinical Excellence and Patient
Safety Awards
100 Most Wired Hospitals in Health Networks
Magazine
Institute for Diversity in Healthcares Best in
Class and a Promising Practices
Healthgrades Americas 100 Best Hospitals Award
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• Why this.why now?

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Pursuit of Equitable Care

• National Direction
• Culturally and Linguistically Appropriate Service
  Standards (CLAS)
• Joint Commissions Roadmap Advancing Effective
  Communication, Cultural Competence and Patient-
  and Family-Centered Communication Standards
• American Hospital Associations National Call to
  Action

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A Few Historical Realities .

• Applicable law or comprehensive vision
• Executive authorization or executive leadership
• Language access policy or cultural and
  linguistic competence
• Functional accountability or system integration
• Regulatory compliance or equitable care

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Our Project Disparities Leadership Program
2011-2012AnMed Health Disparities Dashboard
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• Goal
• The goal of our project is to research and
  develop a disparities dashboard to identify and
  strategically address AnMed Healths most
  vulnerable, underserved and costly patient
  populations. The disparities dashboard will be
  adjunct to our system-wide quality management
  strategies.

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Project Objectives

• I. Establish dashboard implementation team
• II. Establish dashboard framework
• III. Establish priority populations
• IV. System engagement
• V. Project Evaluation Phase II Assessment

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Project Status

• Administrative /Executive Support
• Competing organizational priorities
• Moving disparities conversations forward
• Established dashboard framework
• Methodology and Data Set
• Physician Sponsor
• Matt Cline, MD, Assoc. Program Director, Family
  Medicine
• Resources / Implementation Team Talent

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Quality Disparities Dashboard Components

• Disparities
• Diversity Snapshot
• Service Volumes
• Business Line Analysis
• Language Services

• Quality
• Appropriate Care Scores
• HF AMI CAP SCIP
• Patient Satisfaction
• H-CAHPS
• Readmissions

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Diversity Snapshot Diversity Snapshot White Hispanic African American American Indian Asian Unknown/ Other
Setting Setting Percent Percent Percent Percent Percent Percent
Inpatient Discharges Inpatient Discharges 78.63 0.91 19.83 0.25 0.31 0.08
Emergency Department Emergency Department 70.64 1.17 23.59 0.01 0.12 4.47
Child Health Child Health 42.23 7.52 27.09 0.00 0.01 23.14
Family Medicine Family Medicine 65.26 1.85 20.97 0.00 0.00 11.91
               
               
Type of Care Type of Care White Hispanic African American American Indian Asian Unknown/ Other
Service Service Percent of Admissions Percent of Admissions Percent of Admissions Percent of Admissions Percent of Admissions Percent of Admissions
Inpatient Adult Inpatient Adult 59.61 0.72 19.36 0.19 0.24 0.09
Inpatient Pediatrics (lt17) Inpatient Pediatrics (lt17) 73.33 2.19 23.04 0.63 0.78 0.04
AnMed Health Business Line AnMed Health Business Line 78.63 0.91 19.83 0.25 0.31 0.08
  Cardiac Surgery 88.68 0.75 9.43 0.75 0.38 0.00
  Cardiology 74.71 0.40 24.55 0.00 0.27 0.07
  Cath EP 83.37 0.59 15.32 0.13 0.53 0.07
  Dentistry 53.85 7.69 38.46 0.00 0.00 0.00
  ENT 77.25 1.20 20.96 0.00 0.60 0.00
  Gastroenterology 79.93 0.88 18.85 0.20 0.14 0.00
  General Surgery 81.05 1.24 17.22 0.33 0.08 0.08
  Gynecology 72.18 0.70 26.06 1.06 0.00 0.00
  Internal Medicine 78.48 0.54 20.43 0.23 0.27 0.05
  Medical Oncology 69.39 0.00 30.16 0.23 0.23 0.00
  Neonatology 73.16 2.25 23.77 0.41 0.41 0.00
  Nephrology 76.10 0.73 22.96 0.10 0.00 0.10
  Neurology 77.02 0.62 21.49 0.00 0.25 0.62
  Neurosurgery 85.63 0.00 13.22 0.57 0.57 0.00
  Normal Newborn 73.34 2.04 22.98 0.72 0.85 0.07
  Obstetrics 72.67 2.10 23.75 0.62 0.72 0.14
  Opthalmology 25.00 0.00 75.00 0.00 0.00 0.00
  Orthopaedics 87.27 0.29 12.22 0.00 0.22 0.00
  Psychiatric 84.08 0.57 15.06 0.00 0.10 0.19
  Pulmonary 81.03 0.55 18.19 0.08 0.12 0.04
  Thoracic Surgery 82.70 0.00 17.30 0.00 0.00 0.00
  Trauma Burns 82.54 0.79 15.08 0.79 0.79 0.00
  Urology 85.27 0.63 14.11 0.00 0.00 0.00
  Vascular Surgery 68.69 1.22 29.79 0.30 0.00 0.00
FY2011 Diversity Snapshot
Diversity Snapshot Diversity Snapshot White Hispanic African American American Indian Asian Unknown/ Other
Setting Setting Percent Percent Percent Percent Percent Percent
Inpatient Discharges Inpatient Discharges 78.63 0.91 19.83 0.25 0.31 0.08
Emergency Department Emergency Department 70.64 1.17 23.59 0.01 0.12 4.47
Child Health Child Health 42.23 7.52 27.09 0.00 0.01 23.14
Family Medicine Family Medicine 65.26 1.85 20.97 0.00 0.00 11.91
               
               
Type of Care Type of Care White Hispanic African American American Indian Asian Unknown/ Other
Service Service Percent of Admissions Percent of Admissions Percent of Admissions Percent of Admissions Percent of Admissions Percent of Admissions
Inpatient Adult Inpatient Adult 59.61 0.72 19.36 0.19 0.24 0.09
Inpatient Pediatrics (lt17) Inpatient Pediatrics (lt17) 73.33 2.19 23.04 0.63 0.78 0.04
AnMed Health Business Line AnMed Health Business Line 78.63 0.91 19.83 0.25 0.31 0.08
  Cardiac Surgery 88.68 0.75 9.43 0.75 0.38 0.00
  Cardiology 74.71 0.40 24.55 0.00 0.27 0.07
  Cath EP 83.37 0.59 15.32 0.13 0.53 0.07
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National Hospital Quality Measures National Hospital Quality Measures National Hospital Quality Measures National Hospital Quality Measures     1-White 1-Hispanic 2-Black 3-American Indian 4-Asian 7-UTD Total
Heart Failure Heart Failure                      
  Discharge instructions Discharge instructions       97.71 100.00 96.90 0.00 0.00 100.00 97.51
  Evaluation of LVS Function Evaluation of LVS Function       100.00 100.00 100.00 100.00 0.00 100.00 100.00
  ACEI or ARB for LVSD ACEI or ARB for LVSD       99.29 0.00 100.00 0.00 0.00 0.00 99.51
  Adult smoking cessation advice/counseling Adult smoking cessation advice/counseling Adult smoking cessation advice/counseling     100.00 0.00 100.00 0.00 0.00 0.00 100.00
  HF Appropriate Care Score (ACS) HF Appropriate Care Score (ACS)       98.06 0.00 97.37 100.00 0.00 0.00 97.90
AMI AMI                      
  Aspirin at arrival         100.00 100.00 100.00     100.00 100.00
  Aspirin Prescribed at discharge Aspirin Prescribed at discharge       100.00 100.00 100.00     100.00 100.00
  ACEI or ARB for LVSD ACEI or ARB for LVSD       100.00 0.00 100.00     0.00 100.00
  Adult smoking cessation advice / Counseling Adult smoking cessation advice / Counseling Adult smoking cessation advice / Counseling     100.00 0.00 100.00     100.00 100.00
  Beta Blocker prescribed at Discharge Beta Blocker prescribed at Discharge       100.00 100.00 100.00     100.00 100.00
  Inpatient Mortality Not tracked in 2011 Inpatient Mortality Not tracked in 2011       4.76 0.00 6.67     0.00 5.06
  Primary PCI Received Within 90 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival   100.00 0.00 100.00     100.00 100.00
  AMI Appropriate Care Score (ACS) AMI Appropriate Care Score (ACS)       100.00 100.00 98.04     100.00 99.67
  AMI-T1a LDL Cholesterol Assessment AMI-T1a LDL Cholesterol Assessment                    
  AMI-T2 Lipid-Lowering Therapy at Discharge (Test) AMI-T2 Lipid-Lowering Therapy at Discharge (Test) AMI-T2 Lipid-Lowering Therapy at Discharge (Test)                  
Pneumonia Pneumonia                      
  Pneumococcal vaccination Pneumococcal vaccination       99.79 100.00 100.00 0.00 100.00 0.00 99.81
  Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital 99.62 100.00 98.68 100.00 100.00 0.00 99.50
  Adult smoking cessation advice / counseling Adult smoking cessation advice / counseling Adult smoking cessation advice / counseling     100.00 0.00 100.00 0.00 100.00 0.00 100.00
  Influenza vaccination Influenza vaccination       100.00 100.00 100.00 0.00 100.00 0.00 100.00
  Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU 100.00 0.00 100.00 100.00 0.00 0.00 100.00
  Initial antibiotic received within 8 hours of hospital arrival Initial antibiotic received within 8 hours of hospital arrival Initial antibiotic received within 8 hours of hospital arrival Initial antibiotic received within 8 hours of hospital arrival   96.89 100.00 97.14 100.00 100.00 0.00 96.98
  Initial antibiotic selection for CAP in immunocompetent - ICU patient Initial antibiotic selection for CAP in immunocompetent - ICU patient Initial antibiotic selection for CAP in immunocompetent - ICU patient Initial antibiotic selection for CAP in immunocompetent - ICU patient   95.65 0.00 100.00 0.00 0.00 0.00 96.08
  Initial antibiotic selection for CAP in immunocompetent - Non ICU patient Initial antibiotic selection for CAP in immunocompetent - Non ICU patient Initial antibiotic selection for CAP in immunocompetent - Non ICU patient Initial antibiotic selection for CAP in immunocompetent - Non ICU patient   97.58 100.00 97.06 0.00 0.00 0.00 97.52
  Initial Antibiotic Received Within 6 Hours of Hospital Arrival Initial Antibiotic Received Within 6 Hours of Hospital Arrival Initial Antibiotic Received Within 6 Hours of Hospital Arrival Initial Antibiotic Received Within 6 Hours of Hospital Arrival   96.89 100.00 97.14 100.00 100.00 0.00 96.94
  PN Appropriate Care Score (ACS) PN Appropriate Care Score (ACS)       96.78 100.00 96.40 100.00 100.00 0.00 96.75
Surgical Care Surgical Care                      
  Prophylactic abx within 1 hr prior to surgical incision-Overall Rate Prophylactic abx within 1 hr prior to surgical incision-Overall Rate Prophylactic abx within 1 hr prior to surgical incision-Overall Rate Prophylactic abx within 1 hr prior to surgical incision-Overall Rate   98.35 100.00 99.19   0.00   98.49
  Prophylactic abx selection surgical patients-Overall Rate Prophylactic abx selection surgical patients-Overall Rate Prophylactic abx selection surgical patients-Overall Rate Prophylactic abx selection surgical patients-Overall Rate   98.22 100.00 97.58   0.00   98.13
  Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate 98.41 100.00 99.17   0.00   98.54
  Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose 99.15 100.00 93.33   0.00   98.52
  Surgery Patients with Appropriate Hair Removal Surgery Patients with Appropriate Hair Removal Surgery Patients with Appropriate Hair Removal     100.00 100.00 100.00   100.00   100.00
  Surgery Pt on BB Therapy Received BB During Perioperative Period Surgery Pt on BB Therapy Received BB During Perioperative Period Surgery Pt on BB Therapy Received BB During Perioperative Period Surgery Pt on BB Therapy Received BB During Perioperative Period   96.23 100.00 97.67   100.00   96.53
  Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered 99.18 100.00 100.00   0.00   99.32
  Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg 98.57 100.00 97.94   0.00   98.47
  SCIP Appropriate Care Score (ACS) SCIP Appropriate Care Score (ACS)       91.99 100.00 91.98   100.00   92.05
  Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero 93.75 100.00 95.45   0.00   94.09
  Surgery Patients with Perioperative Temperature Management Surgery Patients with Perioperative Temperature Management Surgery Patients with Perioperative Temperature Management Surgery Patients with Perioperative Temperature Management   100.00 100.00 100.00   0.00   100.00

• Appropriate Care Score Populations
• Heart Failure (HF)
• Acute Myocardial Infarction (AMI)
• Pneumonia (CAP)
• Surgical Care (SCIP)

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National Hospital Quality Measures National Hospital Quality Measures National Hospital Quality Measures National Hospital Quality Measures National Hospital Quality Measures National Hospital Quality Measures National Hospital Quality Measures National Hospital Quality Measures     1-White 1-Hispanic 2-Black 3-American Indian 4-Asian 7-UTD Total
Heart Failure Heart Failure                              
  Discharge instructions Discharge instructions               97.71 100.00 96.90 0.00 0.00 100.00 97.51
  Evaluation of LVS Function Evaluation of LVS Function               100.00 100.00 100.00 100.00 0.00 100.00 100.00
  ACEI or ARB for LVSD ACEI or ARB for LVSD               99.29 0.00 100.00 0.00 0.00 0.00 99.51
  Adult smoking cessation advice/counseling Adult smoking cessation advice/counseling Adult smoking cessation advice/counseling Adult smoking cessation advice/counseling Adult smoking cessation advice/counseling Adult smoking cessation advice/counseling Adult smoking cessation advice/counseling     100.00 0.00 100.00 0.00 0.00 0.00 100.00
  HF Appropriate Care Score (ACS) HF Appropriate Care Score (ACS) HF Appropriate Care Score (ACS) HF Appropriate Care Score (ACS)           98.06 0.00 97.37 100.00 0.00 0.00 97.90
AMI AMI                              
  Aspirin at arrival                 100.00 100.00 100.00     100.00 100.00
  Aspirin Prescribed at discharge Aspirin Prescribed at discharge Aspirin Prescribed at discharge Aspirin Prescribed at discharge           100.00 100.00 100.00     100.00 100.00
  ACEI or ARB for LVSD ACEI or ARB for LVSD ACEI or ARB for LVSD ACEI or ARB for LVSD           100.00 0.00 100.00     0.00 100.00
  Adult smoking cessation advice / Counseling Adult smoking cessation advice / Counseling Adult smoking cessation advice / Counseling Adult smoking cessation advice / Counseling Adult smoking cessation advice / Counseling Adult smoking cessation advice / Counseling Adult smoking cessation advice / Counseling     100.00 0.00 100.00     100.00 100.00
  Beta Blocker prescribed at Discharge Beta Blocker prescribed at Discharge Beta Blocker prescribed at Discharge             100.00 100.00 100.00     100.00 100.00
  Inpatient Mortality Not tracked in 2011 Inpatient Mortality Not tracked in 2011 Inpatient Mortality Not tracked in 2011             4.76 0.00 6.67     0.00 5.06
  Primary PCI Received Within 90 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival   100.00 0.00 100.00     100.00 100.00
  AMI Appropriate Care Score (ACS) AMI Appropriate Care Score (ACS)               100.00 100.00 98.04     100.00 99.67
  AMI-T1a LDL Cholesterol Assessment AMI-T1a LDL Cholesterol Assessment                            
  AMI-T2 Lipid-Lowering Therapy at Discharge (Test) AMI-T2 Lipid-Lowering Therapy at Discharge (Test) AMI-T2 Lipid-Lowering Therapy at Discharge (Test) AMI-T2 Lipid-Lowering Therapy at Discharge (Test) AMI-T2 Lipid-Lowering Therapy at Discharge (Test)                      
Pneumonia Pneumonia                              
  Pneumococcal vaccination Pneumococcal vaccination               99.79 100.00 100.00 0.00 100.00 0.00 99.81
  Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital Blood Cultures Performed in the ED Prior to Initial Abx Received in Hospital 99.62 100.00 98.68 100.00 100.00 0.00 99.50
  Adult smoking cessation advice / counseling Adult smoking cessation advice / counseling Adult smoking cessation advice / counseling Adult smoking cessation advice / counseling Adult smoking cessation advice / counseling         100.00 0.00 100.00 0.00 100.00 0.00 100.00
  Influenza vaccination Influenza vaccination               100.00 100.00 100.00 0.00 100.00 0.00 100.00
  Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU Blood cultures w/i 24 hours of hosp arrival-pts transferred/admitted to the ICU 100.00 0.00 100.00 100.00 0.00 0.00 100.00
  Initial antibiotic received within 8 hours of hospital arrival Initial antibiotic received within 8 hours of hospital arrival Initial antibiotic received within 8 hours of hospital arrival Initial antibiotic received within 8 hours of hospital arrival Initial antibiotic received within 8 hours of hospital arrival Initial antibiotic received within 8 hours of hospital arrival       96.89 100.00 97.14 100.00 100.00 0.00 96.98
  Initial antibiotic selection for CAP in immunocompetent - ICU patient Initial antibiotic selection for CAP in immunocompetent - ICU patient Initial antibiotic selection for CAP in immunocompetent - ICU patient Initial antibiotic selection for CAP in immunocompetent - ICU patient Initial antibiotic selection for CAP in immunocompetent - ICU patient Initial antibiotic selection for CAP in immunocompetent - ICU patient       95.65 0.00 100.00 0.00 0.00 0.00 96.08
  Initial antibiotic selection for CAP in immunocompetent - Non ICU patient Initial antibiotic selection for CAP in immunocompetent - Non ICU patient Initial antibiotic selection for CAP in immunocompetent - Non ICU patient Initial antibiotic selection for CAP in immunocompetent - Non ICU patient Initial antibiotic selection for CAP in immunocompetent - Non ICU patient Initial antibiotic selection for CAP in immunocompetent - Non ICU patient       97.58 100.00 97.06 0.00 0.00 0.00 97.52
  Initial Antibiotic Received Within 6 Hours of Hospital Arrival Initial Antibiotic Received Within 6 Hours of Hospital Arrival Initial Antibiotic Received Within 6 Hours of Hospital Arrival Initial Antibiotic Received Within 6 Hours of Hospital Arrival Initial Antibiotic Received Within 6 Hours of Hospital Arrival Initial Antibiotic Received Within 6 Hours of Hospital Arrival       96.89 100.00 97.14 100.00 100.00 0.00 96.94
  PN Appropriate Care Score (ACS) PN Appropriate Care Score (ACS)               96.78 100.00 96.40 100.00 100.00 0.00 96.75
Surgical Care Surgical Care                              
  Prophylactic abx within 1 hr prior to surgical incision-Overall Rate Prophylactic abx within 1 hr prior to surgical incision-Overall Rate Prophylactic abx within 1 hr prior to surgical incision-Overall Rate Prophylactic abx within 1 hr prior to surgical incision-Overall Rate Prophylactic abx within 1 hr prior to surgical incision-Overall Rate Prophylactic abx within 1 hr prior to surgical incision-Overall Rate       98.35 100.00 99.19   0.00   98.49
  Prophylactic abx selection surgical patients-Overall Rate Prophylactic abx selection surgical patients-Overall Rate Prophylactic abx selection surgical patients-Overall Rate Prophylactic abx selection surgical patients-Overall Rate Prophylactic abx selection surgical patients-Overall Rate Prophylactic abx selection surgical patients-Overall Rate       98.22 100.00 97.58   0.00   98.13
  Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate Prophylactic abx discontinued within 24 hrs after surgery end time-Overall Rate 98.41 100.00 99.17   0.00   98.54
  Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Serum Glucose 99.15 100.00 93.33   0.00   98.52
  Surgery Patients with Appropriate Hair Removal Surgery Patients with Appropriate Hair Removal Surgery Patients with Appropriate Hair Removal Surgery Patients with Appropriate Hair Removal Surgery Patients with Appropriate Hair Removal         100.00 100.00 100.00   100.00   100.00
  Surgery Pt on BB Therapy Received BB During Perioperative Period Surgery Pt on BB Therapy Received BB During Perioperative Period Surgery Pt on BB Therapy Received BB During Perioperative Period Surgery Pt on BB Therapy Received BB During Perioperative Period Surgery Pt on BB Therapy Received BB During Perioperative Period Surgery Pt on BB Therapy Received BB During Perioperative Period       96.23 100.00 97.67   100.00   96.53
  Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered 99.18 100.00 100.00   0.00   99.32
  Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg Rcvd Appropriate VTE Prophylaxis w/n 24 Hrs Prior to thru 24 hrs after Surg 98.57 100.00 97.94   0.00   98.47
  SCIP Appropriate Care Score (ACS) SCIP Appropriate Care Score (ACS)               91.99 100.00 91.98   100.00   92.05
  Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero Urinary Catheter Removed on POD 1 or POD 2 With Day of Surgery Being Day Zero 93.75 100.00 95.45   0.00   94.09
  Surgery Patients with Perioperative Temperature Management Surgery Patients with Perioperative Temperature Management Surgery Patients with Perioperative Temperature Management Surgery Patients with Perioperative Temperature Management Surgery Patients with Perioperative Temperature Management Surgery Patients with Perioperative Temperature Management       100.00 100.00 100.00   0.00   100.00
FY2011 Appropriate Care Scores
National Hospital Quality Measures National Hospital Quality Measures National Hospital Quality Measures National Hospital Quality Measures National Hospital Quality Measures National Hospital Quality Measures National Hospital Quality Measures     1-White 1-Hispanic 2-Black
Heart Failure Heart Failure                    
  Discharge instructions Discharge instructions Discharge instructions           97.71 100.00 96.90
  Evaluation of LVS Function Evaluation of LVS Function Evaluation of LVS Function           100.00 100.00 100.00
  ACEI or ARB for LVSD ACEI or ARB for LVSD ACEI or ARB for LVSD           99.29 0.00 100.00
  Adult smoking cessation advice/counseling Adult smoking cessation advice/counseling Adult smoking cessation advice/counseling Adult smoking cessation advice/counseling Adult smoking cessation advice/counseling Adult smoking cessation advice/counseling     100.00 0.00 100.00
  HF Appropriate Care Score (ACS) HF Appropriate Care Score (ACS)             98.06 0.00 97.37
AMI AMI                    
  Aspirin at arrival               100.00 100.00 100.00
  Aspirin Prescribed at discharge Aspirin Prescribed at discharge             100.00 100.00 100.00
  ACEI or ARB for LVSD ACEI or ARB for LVSD             100.00 0.00 100.00
  Adult smoking cessation advice / Counseling Adult smoking cessation advice / Counseling Adult smoking cessation advice / Counseling Adult smoking cessation advice / Counseling Adult smoking cessation advice / Counseling Adult smoking cessation advice / Counseling     100.00 0.00 100.00
  Beta Blocker prescribed at Discharge Beta Blocker prescribed at Discharge Beta Blocker prescribed at Discharge Beta Blocker prescribed at Discharge         100.00 100.00 100.00
  Inpatient Mortality Not tracked in 2011 Inpatient Mortality Not tracked in 2011 Inpatient Mortality Not tracked in 2011 Inpatient Mortality Not tracked in 2011         4.76 0.00 6.67
  Primary PCI Received Within 90 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival   100.00 0.00 100.00
  AMI Appropriate Care Score (ACS) AMI Appropriate Care Score (ACS)             100.00 100.00 98.04
             
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Patient Experiences with Care Patient Experiences with Care White African American American Indian Hispanic Mexican Puerto Rican Hawaiian/Pacific Islander Hawaiian/Pacific Islander Asian
    of Responses in Best Category (9-10 Rating) of Responses in Best Category (9-10 Rating) of Responses in Best Category (9-10 Rating) of Responses in Best Category (9-10 Rating) of Responses in Best Category (9-10 Rating)        
H-CAHPS (Inpatient) H-CAHPS (Inpatient)                  
  Overall Rating 78.70 74.50 80.11 71.43 70.00 71.43 53.85 53.85 50.00
                     
30-Day Readmissions 30-Day Readmissions White Hispanic African American American Indian Asian Unknown/ Other Overall
  Overall Rate 10.85 5.76 11.54 3.85 6.15 5.88 10.90
  Overall Volume 1796 11 482 2 4 1 2296
  Heart Failure Rate 22.08 33.33 22.09 0.00 0.00 0.00 21.94
  Heart Failure Volume 106 1 38 0 0 0 145
  AMI Rate 11.76 0.00 37.04 0.00 0.00 0.00 15.65
  AMI Volume 34 0 20 0 0 0 54
  Pneumonia Rate 14.18 0.00 13.61 0.00 0.00 0.00 14.02
  Pneumonia Volume 133 0 20 0 0 0 153
Language Services Language Services Outpatient Services Outpatient Services Inpatient Services Total
  Spanish 92.73 92.73 86.31 91.21
  Russian 1.66 1.66 1.34 1.58
  Sign Language 2.05 2.05 2.17 2.08
  Other 1.78 1.78 6.62 2.92
  Chinese / Mandarin 1.21 1.21 2.84 1.59
  Arabic 0.12 0.12 0.45 0.20
  Vietnamese 0.38 0.38 0.17 0.33
  Polish 0.03 0.03   0.03
  Farsi (Persian) 0.03 0.03   0.03
  German 0.00 0.00   0.00
  Greek     0.11 0.03
FY2011 H-CAHPS Readmissions Language Services
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Progress and Challenges

• Strategic alignment
• Family Medicine Residency Program
• REaL data collection at registration
• Trending and Data Analysis
• Intervention Team
• Inpatient Focus
• Collaborative and Benchmark Opportunities

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Interventions

• Case Management Involvement
• Real Time Patient Alerts
• Readmission Interview
• Post Discharge Phone Calls
• Cultural Competency Education
• Skills Fair
• Ongoing Relevance Training
• Dashboard Presentations

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Questions
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Contact Information

• Pamela J. Janniere, MBA
• Senior Membership Specialist
• Institute for Diversity in Health Management
• pjanniere_at_aha.org
• 312-422-2691
• Barrett Ludley, MBA
• barrett.ludley_at_anmedhealth.org
• 864-512-1846
• Juana Slade, CDM, CCF
• juana.slade_at_anmedhealth.org
• 864-512-2361
• Suzanne Wilson, RN, MBA
• suzanne.wilson_at_anmedhealth.org
• 864-512-1767