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St. Luke Hospitals
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Commitment to Quality

Measures for Heart Failure Diagnoses

This table shows our percentage of compliance with every patient care standard being measured.  A score of 91% means we were compliant with patient care best practices 91% of the time.

This table illustrates measures for past fiscal years and for each quarter of the current fiscal year.  It shows our percentage of compliance with patient care best practices for adults diagnosed with heart failure.

Core Measures (Reported for recently available quarter: FY07 Q3 ) TRENDED QUALITY DATA
(Most recent 4 years)
  (Most recent 4 quarters)
St. Luke East Heart Failure Care Quality Measures FY03
(Jul 02 - Jun 03)
FY04
(Jul 03 - Jun 04)
FY05
(Jul 04 - Jun 05)
FY06
(Jul 05 - Jun 06)
  FY06 Q4
(Apr 06 - Jun 06)
FY07 Q1
(Jul 06 - Sep 06)
FY07 Q2
(Oct 06 - Dec 06)
FY07 Q3
(Jan 07 - Mar 07)
Benchmark* (Oct 05 -
Sep 06)
  CMS Validated+        
HF-1 Discharge Instructions (%) 47% 53% 54% 49%   84% 88% 80% 76% 75%
HF-2 Assessment Left Ventricular Function (%) 77% 88% 84% 94%   100% 100% 100% 98% 91%
HF-3 ACE Inhibitor for LVSD (%) 69% 67% 81% 67%   71% 71% 69% 70% 84%
HF-4 Adult Smoking Cessation Advice/Counseling (%) 70% 84% 84% 100%   100% 100% 100% 83% 89%
  Heart Attack Composite Score
The "Composite Score Approach" = the sum of the numerators for each measure divided by the sum of the denominators for each measure times 100.
66% 73% 73% 74%   90% 91% 90% 86%  

+ The Centers for Medicare and Medicaid (CMS) audits a sample of patient records to make sure that reported numbers are accurate. The CMS process lags several months behind and so our most recent results have not been validated by CMS yet. Our validation scores are consistently good and we anticipate that the results shown accurately reflect performance for that interval.
* Benchmark from Centers for Medicare and Medicaid - HHS Hospital Compare website, most current benchmark for SW Ohio.

 

Core Measures (Reported for recently available quarter: FY07 Q3 ) TRENDED QUALITY DATA
(Most recent 4 years)
  (Most recent 4 quarters)
St. Luke West Heart
Failure Care Quality Measures
FY03
(Jul 02 - Jun 03)
FY04
(Jul 03 - Jun 04)
FY05
(Jul 04 - Jun 05)
FY06
(Jul 05 - Jun 06)
  FY06 Q4
(Apr 06 - Jun 06)
FY07 Q1
(Jul 06 - Sep 06)
FY07 Q2
(Oct 06 - Dec 06)
FY07 Q3
(Jan 07 - Mar 07)
Benchmark* (Oct 05 -
Sep 06)
  CMS Validated+          
HF-1 Discharge Instructions (%) 29% 29% 48% 55%   75% 100% 89% 67% 75%
HF-2 Assessment Left Ventricular Function (%) 80% 87% 88% 84%   85% 93% 100% 100% 91%
HF-3 ACE Inhibitor for LVSD (%) 68% 72% 69% 70%   62% 79% 50% 67% 84%
HF-4 Adult Smoking Cessation Advice/Counseling (%) 59% 67% 95% 94%   67% 100% 100% 100% 89%
  Heart Attack Composite Score
The "Composite Score Approach" = the sum of the numerators for each measure divided by the sum of the denominators for each measure times 100.
60% 65% 73% 73%   77% 94% 86% 85%  

+ The Centers for Medicare and Medicaid (CMS) audits a sample of patient records to make sure that reported numbers are accurate. The CMS process lags several months behind and so our most recent results have not been validated by CMS yet. Our validation scores are consistently good and we anticipate that the results shown accurately reflect performance for that interval.
* Benchmark from Centers for Medicare and Medicaid - HHS Hospital Compare website, most current benchmark for SW Ohio.

 

Core Measures (Reported for recently available quarter: FY07 Q3 ) CURRENT QUALITY SCORES FOR THE HEALTH ALLIANCE
All Health Alliance
Heart Failure Care Quality Measures

The
Christ Hospital
The University Hospital St. Luke East Hospital St. Luke West Hospital The
Jewish Hospital
Fort Hamilton Hospital Benchmark* (Oct 05 -
Sep 06)
HF-1 Discharge Instructions (%) 87% 93% 76% 67% 82% 100% 75%
HF-2 Assessment Left Ventricular Function (%) 100% 99% 98% 100% 97% 98% 91%
HF-3 ACE Inhibitor for LVSD (%) 86% 93% 70% 67% 86% 94% 84%
HF-4 Adult Smoking Cessation Advice/Counseling (%) 100% 100% 100% 100% 100% 100% 89%
  Heart Failure Composite Score
The "Composite Score Approach" =the sum of the numerators for each measure divided by the sum of the denominators for each measure times 100.
95% 96% 86% 85% 90% 99%  

* Benchmark from Centers for Medicare and Medicaid - HHS Hospital Compare website, most current benchmark for SW Ohio.

Discharge instructions
At discharge, the hospital staff should provide information about managing  heart failure symptoms.

  • This measure shows the percent of heart failure patients who were discharged home with written instructions or educational material addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.

Assessment left ventricular function
This assessment checks how the left chamber of the heart is pumping.

  • This measure shows the percent of heart failure patients with documentation in the hospital record that left ventricular function (LVF) was assessed before arrival, during hospitalization, or is planned for after discharge.

ACE inhibitor for LVSD
ACE inhibitors are medicines used to treat decreased heart function, heart attacks or heart failure.  

LVSD stands for left ventricular systolic dysfunction. When the heart’s left ventrical does not function properly, the risk for additional heart attacks increases.

  • This measure shows the percent of heart failure patients who are prescribed ACE inhibitors at discharge.

Adult smoking cessation advice/ counseling
Smoking is linked to heart attacks. Quitting may help prevent another heart attack.

  • This measure shows the percent of heart attack patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during a hospital stay.

 

Using the tables as a guide for these three areas, you can see our progress year to year and quarter to quarter.

Heart Attack Diagnosis Heart Failure Diagnosis Pneumonia Diagnosis
     

If you have any questions about the information provided on this site, please contact Health Alliance Quality Management Services at QualityManagementServices@healthall.com.

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