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Patient Safety is Our First Priority Core Measures Quality Indicators Process of Care Evidence-Based Medicine 2011 2012 2013 2014 Heart Failure Care Heart Failure Composite 97 99 96 99 Includes all elements of discharge instruction provided left ventricular function assessment ace inhibitor prescribed for heart failure. Stroke Care NYS Stroke Care Composite 93 97 94 98 IV tPA addressed within 2 hours of arrival if indicated antithrombotic therapy blood clot prevention managed blood clot prevention with atrial brillation smoking cessation addressed lipid lowering medications addressed swallowing evaluation completed rehabilitation considered NIHSS completed on admission or discharge. Surgical Infection Prevention Surgical Infection Prevention Composite 98 99.5 99 99 Includes appropriate antibiotic given within one hour of incision appropriate hair removal appropriate medications indicated for blood clot prevention indications for beta blocker addressed preoperatively antibiotics appropriately discontinued urinary catheter removed by post-op day 2 pre-operative temperature managed. Myocardial Infarction Heart Attack Myocardial Infarction Composite 95 95 96 99 Includes aspirin upon arrival aspirin prescribed at discharge ACEI and ARB for LVSD beta blocker at discharge lipid-lowering therapy at discharge. Pneumonia Care Pneumonia Care Composite 97 98 98 95 Includes blood culture drawn prior to antibiotic administration appropriate antibiotic use inuenza and pneumococcal vaccine administration. DAYS SINCE OUR LAST FALL DAYS SINCE OUR LAST PRESSURE ULCER OTHER BEST PRACTICES Tips for Preventing Falls Tips for Preventing Ulcers Tips for Best Practices Hourly Rounding Reactivating Bed Alarms Prompt Response to Call Bells and Bed Bells Fall Huddles Gait Belt Turn and Position q2Hours Elevate Heels off Bed Maintain Adequate Nutrition Braden Assessment Attend Use - Fitted Properly Changed is it Necessary Offer Flu Vaccine Offer Pneumonia Vaccine Prevent Blood Clots Provide Disease Specic Patient Education Provide Complete Discharge Instructions Including Patients are being encouraged to take an active role in their own safety. Thompsons visual management boards publicly display days since last fall pressure ulcer and infection in an effort to partner with our patients to decrease hospital-acquired events and improve patient care. We recognize the crucial role of patients perspectives in establishing a culture of safety. We are committed to engaging patients and their families in the design and nurturing of safety efforts while emphasizing transparency through the use of our boards. Mean Linear F.F. Thompson Hospital Catheter-Associated Urinary Tract Infections CAUTI per 1000 Foley Days 2012 2013 2014 0 2 4 6 8 Q4Q3Q2Q1Q4Q3Q2Q1Q4Q3Q2Q1 Aggregated MedicalSurgical and ICU Falls with Injury per 1000 Patient Days 2012 2013 2014 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 Q4Q3Q2Q1Q4Q3Q2Q1Q4Q3Q2Q1 Ventilator-Associated Pneumonias per 1000 Ventilator Days ICU VAP per 1000 Ventilator Days 2012 2013 2014 0 2 4 6 8 10 12 Q4Q3Q2Q1Q4Q3Q2Q1Q4Q3Q2Q1 Hospital Central Line Associated Blood Stream Infection CLABSI per 1000 Line Days 2012 2013 2014 0 1 2 3 4 Q4Q3Q2Q1Q4Q3Q2Q1Q4Q3Q2Q1 Accurage Medication List Follow-Up Appointments Myocardial Infarction Composite Includes aspirin upon arrival aspirin prescribed at discharge ACEI and ARB for LVSD beta blocker at discharge lipid-lowering therapy at discharge. Pneumonia Care Pneumonia Care Composite 97 98 98 95 Includes blood culture drawn prior to antibiotic administration appropriate antibiotic use inuenza and pneumococcal vaccine administration. Mean Linear F.F. Thompson Hospital 2012 2013 2014 0 Q4Q3Q2Q1Q4Q3Q2Q1Q4Q3Q2Q1 2014 Financial Statement 15