Quality & Safety
- A Letter from Chris Barber & Michael Givens
- Quality Measures
- Safety Measures
- Satisfaction Measures
- Cost Measures
- Outside Links
- Quality Awards
- Quality & Safety Report
A Letter from Chris Barber & Michael Givens
More than 100 years ago, the Olivetan Benedictine Sisters made a lasting promise in their founding mission to provide Christ-like healing to the community through education, treatment and health services. Every decision since – with regard to technology, innovation, infrastructure or patient care – has been made with that pledge at heart.
At. St. Bernards Healthcare, we believe the best way to honor the Sisters’ founding intent is to ensure the highest standard of quality applies to every facet of our operation. To facilitate quality control and constant improvement in all areas of care, we measure our progress and benchmark those results against other facilities of comparable size and scope in the state and nation.
We then openly share the information we collect which is what you will find in this Quality & Safety Report.
The information provided to you is to enable you to make an informed decision about your care. As your trusted provider of healthcare services, we take pride in our results that demonstrate our commitment to providing the highest quality, safest and most affordable healthcare available.
Quality Measures Back to Top
Every year, about one million people suffer a heart attack or acute myocardial infarction (AMI). Scientific evidence indicates that the following measures represent the best practices for the treatment of AMI. The goal is to achieve 100% on all measures.
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 left ventricular systolic dysfunction
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 Received Within 90 Minutes Of Hospital 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 age 65 or older. Substantial scientific evidence indicates that the following measures represent the best practices for the treatment of heart failure. The goal is to achieve 100% on the measures.
Assessment of left ventricular function (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 left ventricular systolic dysfunction
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.
Heart failure patients and/or their care givers are given written instructions or education material upon discharge addressing all of the following:
- Activity Level
- Discharge Medications
- Follow-Up Appointment
- Weight Monitoring
- and 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, causing 4 million episodes of illness and nearly one million hospital admissions each year. Scientific evidence indicates that the following measures represent the best practices for the treatment of community-acquired pneumonia:
Initial Antibiotic Timing
Pneumonia inpatients receive within six hours after hospital arrival. Evidence shows better outcomes for administration times less than six hours.
Pneumococcal Vaccination Status
Pneumonia inpatients age 65 and older are screened for pneumococcal vaccine status and are administrated the vaccine prior to discharge, if indicated.
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 the right treatment at the right time. Studies show a strong association of reduced incidence of post-operative infection and other complications when surgical patients receive prophylactic antibiotics within one hour prior to surgical incision and discontinuation in the antibiotics within 24 hours after surgery end time.
Our hospital staff makes sure all patients get the antibiotic that works best for their type of surgery.
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" means their blood sugar should be 200 mg/dL or less when checked first thing in the morning.
Preparing a patient for surgery may include removing body hair from skin in the area where the surgery will be done. Medical research has shown that shaving with a razor can increase the risk of infection. It is safer to use electric clippers or hair removal cream.
Certain surgeries increase the risk that the patient will develop a blood clot (venous thromboembolism). When patients stay still for a long time after some types of surgery, they are more likely to develop a blood clot 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 is a serious problem that 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, which is typically during the period that begins 24 hours before surgery and ends 24 hours after surgery.
Children's Asthma Care
Asthma is the most common chronic disease in children and for children, is one of the most frequent reasons for admission to hospitals, with approximately 200,000 admissions in the United States each year. Under-treatment and/or inappropriate treatment of asthma are recognized as major contributors to asthma complications and death.
Scientific evidence indicates that the following measures represent the best practices for the treatment and management of asthma in the hospital:
- Use of Relievers – To improve breathing while in the hospital
- Systemic Corticosteroids – To quickly gain control of asthma and reduce the severity of asthma while in the hospital
- Home Management Plan – To help maintain control of asthma at home if it gets worse.
Adult Psychiatric Measures
Admission screening for violence risk, substance use, psychological trauma history and patient strengths
Professional literature suggests that these factors are under-identified yet integral to current psychiatric status and should be assessed in order to develop appropriate treatment. Similarly, persons admitted to inpatient settings require a careful assessment of risk for violence and the use of seclusion and restraint. Careful assessment of risk is critical to safety and treatment. Effective, individualized treatment relies on assessments that explicitly recognize patients' 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.
Research studies have found that 4-35% of outpatients and 30-50% of inpatients treated with an antipsychotic medication concurrently received 2 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 report to their next level of care healthcare provider their course of hospitalization or discharge treatment recommendations. 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.
Safety Measures Back to Top
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 attack, 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 particular 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 particular 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. So, 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.
Satisfaction Measures Back to Top
The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) 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 that 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.
Cost Measures Back to Top
All information in this 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:
Definitions in 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% 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.
IT IS IMPORTANT TO REMEMBER THAT ACTUAL PAYMENTS TO THE HOSPITAL MAY DIFFER SIGNIFICANTLY FROM CHARGES. THE MEDICARE PROGRAM MAKES FIXED PAYMENTS FOR MS-DRG'S REGARDLESS OF A HOSPITAL'S CHARGES AND INSURANCE COMPANIES MAY NEGOTIATE DISCOUNTED PAYMENT ARRANGEMENTS.
Back to Top Quality Awards
- Arkansas Foundation for Medical Care Innovation In Health Care
- VHA 2011 Regional Clinical Award for Clinical Excellence in Acute Myocardial Infarction and Surgical Care Infection Prevention
- VHA 2011 Regional Clinical Award for Clinical Excellence in Prevention of Complications for Catheter-Associated Blood Stream Infections
2010 VHA Oklahoma/Arkansas Quality Awards
- Regional Clinical Improvement Award-Core Measure Performance-Heart Attack
- Regional MRSA Infection Control Award-Recognition of High Performance-Hand Hygiene, Use of Barrier Protection
- Regional MRSA Infection Control Award-Recognition of Improved Performance-Hand Hygiene, Use of Barrier Protection
- 2010 Arkansas Foundation for Medical Care Innovator Award
- 2009 Arkansas Foundation for Medical Care Innovator Award
- St. Bernards Center for Weight Loss received HMR's gold standard award in 2008 & 2009
- 2007 Arkansas Foundation for Medical Care Innovator Award
- St. Bernards Diabetes Management Center is recognized by the American Diabetics Association.
- St. Bernards Surgical ICU received the Medal of Honor for Organ Donation from the Department of Health and Human Services for the past 4 years.
- St. Bernards has received the Medal of Honor for Organ Donation from the Department of Health and Human services for a number of years.
- St. Bernards Dialysis received awards in 2009 from the ESRD Network 13 for forms Compliance and Maintaining Consistent Records with Patient Data Forms being accurate and timely.
- St. Bernards Pet Center was the first PET Center in Arkansas to be accreted by the American Collage of Radiology in P.E.T. Oncology and Neurological imaging. The PET Center is also credentialed by the U.S. Imaging Network in P.E.T. imaging.
- St. Bernards Home Health continues to receive the Home Health Home Care Elite Award of Excellence for recognition as one of the top 500 agencies nationwide whose performance measures at the top in quality, improvement and financial performance.