More than a century ago, the Olivetan Benedictine Sisters made it their mission to provide Christ-like healing to those in need. At. St. Bernards Healthcare, we continue to fulfill their promise to the community by providing education, treatment and health services. And we honor their selfless commitment by pushing our organization to achieve the highest quality standards in everything we do.
St. Bernards accomplishes this through quality control and the pursuit of continuous improvement in all areas of care. We measure key indicators to monitor quality and benchmark those results against our past performance, industry quality standards, and other state and national health systems.
It is an honor to be entrusted with your care. Sharing the quality and safety information we collect enables you to make informed decisions and demonstrates our commitment to providing the safest, highest quality and most affordable healthcare available.
Each year, nearly one million people suffer an acute myocardial infarction (AMI), commonly known as a heart attack. Our goal is to achieve 100percent on these measures, universally accepted as the best practices for the heart attack treatment.
- Aspirin at arrival: AMI patients without aspirin contraindications receive aspirin within 24 hours of their hospital arrival.
- Aspirin at discharge: AMI patients without aspirin contraindications are prescribed aspirin at hospital discharge.
- ACE inhibitor or ARB for LVSD: AMI patients with left ventricular systolic dysfunction (LVSD) and without angiotensin converting enzyme inhibitor (ACE inhibitor) contraindications or angiotensin receptor blocker (ARB) contraindications are prescribed an ACE inhibitor or an ARB at hospital discharge.
- Beta Blocker at discharge: AMI patients without beta-blocker contradictions are prescribed a beta-blocker at hospital discharge.
- PCI within 90 minutes of arrival: AMI patients receive Percutaneous Coronary Intervention (PCI) within 90 minutes of hospital arrival.
- Adult smoking cessation advice/counseling: AMI patients with a history of smoking cigarettes are given smoking cessation advice or counseling during their hospital stay.
Heart failure is the most common hospital admission diagnosis in patients 65 or older. Scientific evidence indicates the following measures are the best practices for heart failure treatment. The goal is to achieve 100% on the measures.
- Assessment of LVF: heart failure patients with documentation undergo a left ventricular function (LVF) assessment either before arrival, during hospitalization or it is planned for after discharge.
- ACE inhibitor or ARB for LVSD: heart failure patients with left ventricular systolic dysfunction (LVSD) and without angiotensin converting enzyme inhibitor (ACE inhibitor) contraindication or angiotensin receptor blocker (ARB) contraindications are prescribed an ACE inhibitor or an ARB at hospital discharge.
- Discharge instructions: as part of the discharge process, heart failure patients and/or care givers are given written instructions or education material addressing the following:
- Activity Level
- Discharge medications
- Follow-Up appointment
- Weight monitoring
- What to do if symptoms worsen
- Adult smoking cessation advice/counseling: heart failure patients with a history of smoking cigarettes are given smoking cessation advice or counseling during their hospital stay.
Pneumonia is a major contributor to illness and mortality in the United States. It causes four million episodes of illness and nearly one million hospital admissions each year. These measures represent the current best practices for the treatment of community-acquired pneumonia.
- Initial antibiotic timing: pneumonia inpatients receive antibiotics within six hours of hospital arrival.
- Pneumococcal vaccination status: pneumonia inpatients 65 and older are screened for pneumococcal vaccine status and are administrated the vaccine prior to discharge, if indicated.
- Oxygenation assessment: pneumonia inpatients receive an oxygenation assessment, arterial blood gas (ABG), or pulse oximetry within 24 hours of hospital arrival.
- Blood culture performed prior to first antibiotic received in hospital: pneumonia patients have blood culture performed prior to first antibiotic received in the hospital.
- Adult smoking cessation advice/counseling: pneumonia patients with a history of smoking cigarettes are given smoking cessation advice or counseling during their hospital stay.
- Appropriate initial antibiotic selection: immunocompetent patients with pneumonia receive an initial antibiotic regimen that is consistent with current guidelines.
Surgical Infection Prevention
Hospitals can reduce the risk of complications after surgery, including infection and development of blood clots, by providing appropriately timed treatment.
Studies show a strong association of reduced incidence of post-operative infection and other complications when surgical patients receive prophylactic antibiotics one hour prior to surgical incision and discontinuation of the antibiotics within 24 hours post-surgery.
Antibiotics are determined by what works best for certain types of surgery and the patient.
Even if heart surgery patients do not have diabetes, keeping their blood sugar under good control after surgery lowers the risk of infection and other problems. Under good control is defined as blood sugar 200 mg/dL or less when checked first thing in the morning.
Preparing a patient for surgery may include removing body hair in the surgical area with electric clippers or hair removal cream. Razors are not used, as they are determined by medical research to increase the risk of infection.
Certain surgeries increase the risk patients will develop a blood clot (venous thromboembolism). When patients areimmobile after some types of surgery, they are more susceptible to blood clots in the veins of the legs, thighs, or pelvis. A blood clot slows down the flow of blood, causing swelling, redness and pain. A blood clot can also break off and travel to other parts of the body. If the blood clot gets into the lung, it can cause death. To help prevent blood clots from forming after surgery, doctors can order treatments to be used just before or after the surgery. These include blood-thinning medications, elastic support stockings, or mechanical air stockings that help with blood flow in the legs. These treatments need to be started at the right time, typically beginning 24 hours before surgery and ending 24 hours after surgery.
Children's Asthma Care
Asthma is the most common chronic disease in children. It is one of the most common reasons for hospitalizations for children, with approximately 200,000 admissions nationwide each year. Under-treatment and/or inappropriate treatment of asthma are recognized as major contributors to asthma complications and death.
The following measures represent the best practices for the treatment and management of asthma in the hospital:
- Use of relievers: medications and treatments to improve breathing.
- Systemic corticosteroids: using steroids to quickly gain control of asthma and reduce the severity.
- Home management plan: an action plan to help maintain control of asthma at home if it worsens.
Adult Psychiatric Measures
- Admission screening for violence risk, substance use, psychological trauma history and patient strengths: professional literature suggests these factors are under-identified yet integral to current psychiatric status and should be assessed to develop appropriate treatment. Similarly, persons admitted to inpatient settings require a careful assessment of risk for violence and determining use of seclusion and restraint. Careful assessment of risk is critical to safety and treatment. Effective, individualized treatment relies on assessments that explicitly recognize patient strengths.
- Hours of physical restraint and seclusion use: mental health providers that value and respect an individual's autonomy, independence and safety seek to avoid the use of dangerous or restrictive interventions at all times. The use of seclusion and restraint is limited to situations deemed to meet the threshold of imminent danger and when restraint and seclusion are used, such use is rigorously monitored and analyzed to prevent future use.
- Antipsychotic medications: Research studies have found that 4-35 percent of outpatients and 30-50 percent of inpatients treated with an antipsychotic medication concurrently received two or more antipsychotics. Practice guidelines recommend the use of a second antipsychotic only after multiple trials of a single antipsychotic have proven inadequate.
- Post discharge continuing careplan and transmission to next provider of care: patients may not be able to fully convey their course of hospitalization or discharge treatment recommendations to their next level of care healthcare provider. The aftercare instructions given the patient may not be available to the next level of care provider at the patient's initial intake or follow-up appointment. In order to provide optimum care, next level of care providers need to know details of precipitating events immediately preceding hospital admission, the patient's treatment course during hospitalization, discharge medications and next level of care recommendations.
The 30-day risk-adjusted mortality measures for heart attack, heart failure and pneumonia are produced from Medicare claims and enrollment data using a sophisticated statistical model. The model predicts patient-level deaths for any cause within 30 days of hospital admission for heart attack, heart failure or pneumonia, whether the patient dies while still in the hospital or dies after discharge. It calculates a "risk-adjusted" hospital mortality rate that can be used to compare mortality across hospitals. Mortality measures for heart attack, heart failure and pneumonia based on this model have been endorsed by the National Quality Forum (NQF), the non-profit public-private partnership organization that endorses national healthcare performance measures.
The statistical model for computing 30-day risk-adjusted mortality rate measures is a "hierarchical regression model." This type of model is based on the assumption that any heart attack, heart failure or pneumonia patients treated at a particular hospital will experience a level of quality of care that applies to all patients treated for the same condition in that hospital. In other words, the expected risk of death for two similar heart attacks, heart failure or pneumonia patients treated in the same hospital would be more alike than the risk of death for the same two patients treated in two different hospitals.
The likelihood that an individual patient will die is therefore a combination of:
- his or her individual risk characteristics (for example, gender, comorbidities, and past medical history)
- the hospital's unique quality of care for all patients treated for that condition in that hospital.
The model estimates the effects of both of these components on mortality.
Calculation of Mortality Rates
Each hospital's 30-day risk-adjusted mortality rate is computed in several steps. First, the predicted 30-day mortality for a hospital obtained from the hierarchical regression model is divided by the expected mortality for that hospital, which is also obtained from the regression model. Predicted mortality is the rate of deaths from heart attack or heart failure or pneumonia that would be anticipated in the hospital during the 12-month period, given the patient case mix and the hospital's unique quality of care effect on mortality.
Expected mortality is the rate of deaths from heart attack, heart failure or pneumonia that would be expected if the same patients with the same characteristics had instead been treated at an "average" hospital, given the average hospital's quality of care effect on mortality for patients with that condition. This ratio is then multiplied by the national unadjusted mortality rate for the condition for all hospitals to compute a risk-adjusted mortality rate for the hospital. The higher a hospital's predicted 30-day mortality rate, relative to expected mortality for the hospital's particular case mix of patients, the higher its adjusted mortality rate will be. Hospitals with better quality will have lower rates.
The HospitalConsumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was used to collect information. This survey asks patients about their experiences with care during a recent overnight stay in the hospital and allows consumers to make fair and objective comparisons between hospitals. All hospitals use the same survey questionnaire and standardized data collection procedures. The HCAHPS survey does not replace surveys hospitals may do on their own.
The HCAHPS survey was developed by a partnership of public and private organizations. Development of the survey was funded by the Federal government, specifically the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ). The survey asks patients to give feedback about topics for which they are the best source of information; patients only answer questions about topics with which they have experience.
The goal is for each hospital to get at least 300 completed patient surveys, per year. In general, the more patients that respond to a hospital's survey, the more the results shown on this website will reflect the experiences of all the patients who used that hospital. Patients are randomly selected to participate in the HCAHPS survey. Hospitals are not allowed to choose which patients are selected.
All short-term, acute care, non-specialty hospitals are invited to participate in the HCAHPS survey and most hospitals choose to participate. Specialty hospitals and children's hospitals are not included. Hospitals can choose to conduct the survey in one of four ways: by mail, by telephone, by mail and telephone, or by active interactive voice recognition (IVR). Regardless of how the survey is conducted, all patients answer the same questions.
Patients complete the HCAHPS survey after they leave the hospital. Data analysis is done by CMS, not by the hospitals. CMS uses an independent contractor to analyze the HCAHPS survey data and prepare it for reporting.
Data analysis is designed to help ensure fair comparisons among hospitals. Preparing the data for public reporting includes taking certain factors into account in ways that help ensure fair comparisons among hospitals. For example, the mix of patients can differ from one hospital to the next, and these differences in the patient mix can affect a hospital's HCAHPS results. Data preparation takes these differences into account so that the survey results reported are what would be expected for each hospital if all hospitals had a similar mix of patients.
All information in the Quality & Safety report is taken from Hospital Discharge Data which is updated annually by the Arkansas Department of Health Center for Health Statistics. The file includes billing data for 100% of all inpatient claims for discharges during the calendar year. Our report is based on the most recent period available and is consistent with data release policies of the Arkansas Department of Health Center for Health Statistics.
Statistics are reported by Medicare Severity-adjusted Diagnosis Related Groups (MS-DRGs) according to diagnostic information, the procedures performed, patient age and other factors. Our report is based on MS-DRGs, but uses modified descriptions to make them easier to read and understand. The MS-DRGs with the highest charges (as ranked for Arkansas hospitals) are reported:
Cost Definitions for Inpatient Services
Categories: MS-DRGs are categorized for review. These categories are unique to this website.
Description: simplified descriptions are used instead of the technical terminology associated with MS-DRGs. MS-DRG numbers are included within parentheses as part of the description.
Patients: the total number of patients in the MS-DRG category for the 12-month period being reported.
ALOS: the average length of stay (in days) for patients in the MS-DRG category.
Hospital's Charge Range: average hospital charges for a MS-DRG are reported as well as the "Higher" and "Lower" ends of the range representing about 68 percent of all patients. (Statistically, this is referred to as +/- one standard deviation from the mean.) PLEASE NOTE: In some situations (e.g. when there are only a small number of patients in a MS-DRG), a blank will appear if it is not possible to calculate a reasonable "Lower" end.
Please note: actual payments to the hospital may differ significantly from charges. The Medicare program makes fixed payments for MS-DRGs, regardless of a hospital’s charges, and insurance companies may negotiate different rates with St. Bernards.