accreditation quality report - apps.jointcommission.org

Accreditation Quality Report

Version: 4

Central DuPage Hospital AssociationDBA: Northwestern Medicine Central DuPage Hospital,25 North Winfield Road, Winfield, IL Org ID: 7444

Date: 3/30/2020


Welcome to the Joint Commission's Quality Report. We know howimportant reliable information is to you and your family when makinghealth care decisions. This Quality Report will help you make the rightdecisions to meet your needs. Since 1951, the Joint Commission has beenthe national leader in setting standards for health care organizations.When a health care organization seeks accreditation, it demonstratescommitment to giving safe, high quality health care and to continuallyworking to improve that care. The Quality Report is only one way to determine whether a health careorganization can meet your needs. Discuss this report with your doctor orwith other professional acquaintances before making a care decision. Inaddition to the accreditation status of the organization, the Quality Reportuses checks, pluses, and minuses in each of the following key areas tohelp you compare a health care organization with similar accreditedorganizations. • National Patient Safety Goals - safety guidelines that target the

prevention of medical errors such as surgery on the wrong side ofthe body and safe medication use.

• National Quality Improvement Goals - measures the care of patientswith specific conditions such as heart failure or pregnancy.

Not all measures are relevant to or available for all types of health careorganizations. The Joint Commission will add relevant measures of healthcare quality as more measures become available. Your comments are justas important to us. The content and format of the Quality Report will beupdated from time to time based on changes in the health care industryand your suggestions. Please call Customer Service at 630-792-5800 ore-mail the Joint Commission at [email protected] withyour comments and suggestions.

Mark R. Chassin, MD, MPP, MPHPresident of the Joint Commission


3 © Copyright 2022, The Joint Commission

For further informationand explanation of theQuality Report contents,refer to the "QualityReport User Guide."

Summary of Quality Information

Other Accredited Programs/Services

Special Quality Awards

Symbol KeyThis organization achieved the bestpossible results.

This organization’s performance isabove the target range/value.

This organization’s performance issimilar to the target range/value.

This organization’s performance isbelow the target range/value.

This Measure is not applicable for thisorganization.

Not displayed

Footnote Key1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

The Measure or Measure Set was notreported.

The Measure Set does not have anoverall result.

The number of patients is not enoughfor comparison purposes.

The measure meets the PrivacyDisclosure Threshold rule.

The organization scored above 90% butwas below most other organizations.

The Measure results are not statisticallyvalid.

The Measure results are based on asample of patients.

The number of months with Measuredata is below the reporting requirement.

The measure results are temporarilysuppressed pending resubmission ofupdated data.

Test Measure: a measure beingevaluated for reliability of theindividual data elements or awaitingNational Quality Forum Endorsement.

There were no eligible patients that metthe denominator criteria.

• Hospital ( Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC))

•2012 Silver - The Medal of Honor for Organ Donation•2010 Silver - The Medal of Honor for Organ Donation

Compared to other Joint Commission Accredited

Organizations Nationwide Statewide

The Joint Commission only reports measures endorsed by the National Quality Forum.

BehavioralHealthCare

2019National Patient Safety Goals *

Hospital 2019National Patient Safety Goals *

Accreditation Programs Accreditation Decision EffectiveDate

Last Full SurveyDate

Last On-SiteSurvey Date

Behavioral Health Care Accredited 11/20/2019 11/19/2019 11/19/2019

Hospital Accredited 11/23/2019 11/22/2019 11/22/2019

Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS)Hospital

Advanced CertificationPrograms

Certification Decision EffectiveDate

Last Full ReviewDate

Last On-SiteReview Date

Advanced ComprehensiveStroke Center

Certification 3/7/2019 3/6/2019 3/6/2019

Heart Failure Certification 2/21/2019 2/20/2019 2/20/2019

http://www.jointcommission.org/qualitycheck/06_glossary#National_Quality_Forum




Summary of Quality Information Symbol Key

This organization achieved the bestpossible results.




This Measure is not applicable for thisorganization.

Not displayed

Footnote Key1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

The Measure or Measure Set was notreported.

The Measure Set does not have anoverall result.

The number of patients is not enoughfor comparison purposes.

The measure meets the PrivacyDisclosure Threshold rule.

The organization scored above 90% butwas below most other organizations.

The Measure results are not statisticallyvalid.

The Measure results are based on asample of patients.

The number of months with Measuredata is below the reporting requirement.

The measure results are temporarilysuppressed pending resubmission ofupdated data.

Test Measure: a measure beingevaluated for reliability of theindividual data elements or awaitingNational Quality Forum Endorsement.

There were no eligible patients that metthe denominator criteria.

Compared to other Joint Commission Accredited

Organizations Nationwide Statewide


National Quality Improvement Goals:

ReportingPeriod:Oct 2018 -Sep 2019

Emergency Department 2 2

Hospital-Based Inpatient Psychiatric Services 2 2

Perinatal Care 2 2



Locations of Care


* Primary Location

Locations of Care Available ServicesCentral DuPage HospitalAssociation *DBA: NorthwesternMedicine Central DuPageHospital25 North Winfield RoadWinfield, IL 60190

Joint Commission Advanced Certification Programs:

Other Clinics/Practices located at this site:

Services:

● Advanced Comprehensive Stroke Center● Heart Failure

● Northwestern Medicine Regional Medical Group

● Behavioral Health (24-hourAcute Care/CrisisStabilization -Adult/Child/Youth)

● Brachytherapy(Imaging/DiagnosticServices)

● Cardiac Catheterization Lab(Surgical Services)

● Cardiac Surgery (SurgicalServices)

● Cardiothoracic Surgery(Surgical Services)

● Cardiovascular Unit(Inpatient)

● Coronary Care Unit(Inpatient)

● CT Scanner(Imaging/DiagnosticServices)

● Ear/Nose/Throat Surgery(Surgical Services)

● EEG/EKG/EMG Lab(Imaging/DiagnosticServices)

● Gastroenterology (SurgicalServices)

● GI or Endoscopy Lab(Imaging/DiagnosticServices)

● Gynecological Surgery(Surgical Services)

● Gynecology (Inpatient)● Hazardous MedicationCompounding (Inpatient)

● Hematology/Oncology Unit(Inpatient)

● Inpatient Unit (Inpatient)● Interventional Radiology(Imaging/DiagnosticServices)

● Labor & Delivery (Inpatient)● Magnetic ResonanceImaging (Imaging/DiagnosticServices)

● Medical /Surgical Unit(Inpatient)

● Medical ICU (Intensive CareUnit)

● Neuro/Spine Unit (Inpatient)● Neurosurgery (SurgicalServices)

● Non-Sterile MedicationCompounding (Inpatient)

● Normal Newborn Nursery(Inpatient)

● Nuclear Medicine(Imaging/Diagnostic Services)

● Ophthalmology (SurgicalServices)

● Orthopedic Surgery (SurgicalServices)

● Orthopedic/Spine Unit(Inpatient)

● Outpatient Clinics (Outpatient)● Pediatric Unit (Inpatient)● Plastic Surgery (SurgicalServices)

● Positron Emission Tomography(PET) (Imaging/DiagnosticServices)

● Post Anesthesia Care Unit(PACU) (Inpatient)

● Radiation Oncology(Imaging/Diagnostic Services)

● Sleep Laboratory (SleepLaboratory)

● Sterile MedicationCompounding (Inpatient)

● Surgical ICU (Intensive CareUnit)

● Surgical Unit (Inpatient)● Teleradiology(Imaging/Diagnostic Services)

● Thoracic Surgery (SurgicalServices)

● Ultrasound(Imaging/Diagnostic Services)

● Urology (Surgical Services)● Vascular Surgery (SurgicalServices)


Locations of Care


* Primary Location

Locations of Care Available Services

Northwestern MedicineCancer CenterWarrenville4405 Weaver ParkwayWarrenville, IL 60555

Services:

Northwestern MedicineCDH Behavioral HealthServices27W350 High Lake RoadWinfield, IL 60190

Services:

Northwestern MedicineCDH Cardiac ,Pulmonary Rehab7 Blanchard Circle, FirstFloor, WheatonWheaton, IL 60187

Services:

Northwestern MedicineCDH Diagnostic ImagingBloomingdale235 S. Gary AvenueBloomingdale, IL 60108

Services:

Northwestern MedicineCDH Diagnostic ImagingGlen Ellyn885 Roosevelt Road,Suite 101Glen Ellyn, IL 60137

Services:

Northwestern MedicineCDH Diagnostic ImagingNaperville636 N. Raymond Drive,Suite 106Naperville, IL 60563

Services:

Northwestern MedicineCDH Diagnostic ImagingWheaton2001 S. Wiesbrook Ave.Wheaton, IL 60189

Services:

Northwestern MedicineCDH PT7 Blanchard Circle, SuiteLLAWheaton, IL 60189

Services:

● Neuro/Spine ICU (IntensiveCare Unit)

● Administration of Blood Product (Outpatient)● Administration of High Risk Medications (Outpatient)● Outpatient Clinics (Outpatient)

● Addiction Care/Adult)(Non-detox - Adult)(Detox/Non-detox - Adult)

● Behavioral Health (Day Programs - Adult/Child/Youth)(Non 24 Hour Care - Adult/Child/Youth)(Partial - Adult/Child/Youth)

● Chemical Dependency (Day Programs - Adult)(Non 24 Hour Care - Adult/Child/Youth)(24-hour Acute Care/Crisis Stabilization - Adult)(Partial - Adult)(Non-detox - Adult)(Detox/Non-detox - Adult)

● Outpatient Clinics (Outpatient)







Locations of Care


* Primary Location

Locations of Care Available ServicesNorthwestern MedicineCDH Rehab Bartlett820 Route 59, Bartlett, ILBartlett, IL 60103

Services:

Northwestern MedicineCDH RehabBloomingdale Gary Ave245 South Gary Avenue,Suite 101Bloomingdale, IL 60108

Services:

Northwestern MedicineCDH Rehab CarolStream515 Thornhill Dr., CarolStream, ILCarol Stream, IL 60188

Services:

Northwestern MedicineCDH Rehab Glen Ellyn875 Roosevelt Rd.875 Roosevelt Road, GlenEllynGlen Ellyn, IL 60137

Services:

Northwestern MedicineCDH Rehab Glen Ellyn885 Roosevelt885 Roosevelt Rd., GlenEllyn, ILGlen Ellyn, IL 60137

Services:

Northwestern MedicineCDH Rehab Lisle1019 School StreetLisle, IL 60532

Services:

Northwestern MedicineCDH Rehab Naperville75th St.101 East 75th St.,Naperville, ILNaperville, IL 60565

Services:

Northwestern MedicineCDH Rehab ServicesNaperville636 Raymond Dr., Suite305Naperville, IL 60563

Services:

Northwestern MedicineCDH Rehab ServicesSouth Elgin544 Randall RoadSouth Elgin, IL 60177

Services:

Northwestern MedicineCDH Rehab Services St.Charles2900 Foxfield Road, Suite205Saint Charles, IL 60174

Services:












Locations of Care


* Primary Location

Locations of Care Available ServicesNorthwestern MedicineCDH Rehab ServicesWeaver Rd.4405 Weaver ParkwayWarrenville, IL 60555

Services:

Northwestern MedicineCDH Rehab WarrenvilleOT27650 Ferry Rd., FirstFloor, Warrenville, ILWarrenville, IL 60555

Services:

Northwestern MedicineCDH Rehab WarrenvillePT27650 Ferry Rd, LowerLevel, Warrenville, ILWarrenville, IL 60555

Services:







2019 National Patient Safety Goals

Symbol Key Behavioral Health Care

Safety Goals Organizations Should Implemented

Improve the accuracy of theidentification of individualsserved.

Use of Two Identifiers

Improve the safety of usingmedications.

Reconciling Medication Information

Reduce the risk of healthcare-associated infections.

Meeting Hand Hygiene Guidelines

The organization identifiessafety risks inherent in thepopulation of the individualsit serves.

Identifying Individuals at Risk for Suicide

The organization has met the NationalPatient Safety Goal.

The organization has not met theNational Patient Safety Goal.

The Goal is not applicable for thisorganization.




2019 National Patient Safety Goals

Symbol Key Hospital

Safety Goals Organizations Should Implemented

Improve the accuracy ofpatient identification.

Use of Two Patient Identifiers

Improve the effectiveness ofcommunication amongcaregivers.

Timely Reporting of Critical Tests and Critical Results

Improve the safety of usingmedications.

Labeling Medications

Reduce the harmassociated with clinicalalarm systems.

Use Alarms Safely on Medical Equipment

Reduce the risk of healthcare-associated infections.

Meeting Hand Hygiene Guidelines

The organization identifiessafety risks inherent in itspatient population.

Identifying Individuals at Risk for Suicide

Universal Protocol Conducting a Pre-Procedure Verification Process

The organization has met the NationalPatient Safety Goal.

The organization has not met theNational Patient Safety Goal.

The Goal is not applicable for thisorganization.

Eliminating Transfusion Errors

Reducing Harm from Anticoagulation Therapy

Reconciling Medication Information

Preventing Infections that are difficult to treat

Preventing Central-Line Associated Blood Stream Infections

Preventing Surgical Site Infections

Preventing Catheter-Associated Urinary Tract Infection

Marking the Procedure Site

Performing a Time-Out




Symbol KeyThis organization achieved the bestpossible results




Not displayed

Footnote Key1. The Measure or Measure Set was not

reported.

2. The Measure Set does not have anoverall result.

3. The number of patients is not enoughfor comparison purposes.

4. The measure meets the PrivacyDisclosure Threshold rule.

5. The organization scored above 90% butwas below most other organizations.

6. The Measure results are not statisticallyvalid.

7. The Measure results are based on asample of patients.

8. The number of months with Measuredata is below the reporting requirement.

9. The measure results are temporarilysuppressed pending resubmission ofupdated data.

10. Test Measure: a measure beingevaluated for reliability of theindividual data elements or awaitingNational Quality Forum Endorsement.

11. There were no eligible patients that metthe denominator criteria.

National Quality Improvement Goals

Reporting Period: October 2018 - September 2019

Admit Decision Time to EDDeparture Time for AdmittedPatients

The amount of time (in minutes) ittakes from the time the physiciandecides to admit a patient into thehospital from the EmergencyDepartment until the patient actuallyleaves the ED to go to the inpatientunit.

55.00 134.00 61.96 108.66

Compared to other Joint CommissionAccredited Organizations

Nationwide StatewideMeasure Explanation Hospital

ResultsTop 10%Scoredat Most:

Weighted

Median:

Top 10%Scoredat Most:

Weighted

Median:

Compared to other JointCommission

Accredited OrganizationsMeasure Area Explanation Nationwide StatewideEmergencyDepartment

This category of evidence based measures assesses thetime patients remain in the hospital EmergencyDepartment prior to inpatient admission.

2

89.00 minutes512 eligiblePatients


* This information can also be viewed at www.hospitalcompare.hhs.gov---- Null value or data not displayed.

2 2

http://www.hospitalcompare.hhs.gov









Not displayed


reported.













Assessment of violence risk,substance use disorder,trauma and patient strengthscompleted - Overall Rate

This measure reports the overallnumber of patients screened forviolence risk to self and others,substance and alcohol use,psychological trauma history andpatient strengths. Screening forviolence risk to self determines ifpatients are likely to harmthemselves. Screening for violencerisk to others determines if patientsare likely to harm others. Screeningfor substance and alcohol usedetermines if patients need help fortheir use. Screening forpsychological trauma historydetermines if patients haveexperienced terrible events in theirlives which have left them fearful oranxious and unable to handle theirfeelings. Screening for patientstrengths identifies positive thingssuch as family support, a steady job,housing, etc. which are used to helpthe patient recover.

100% 95% 100% 99%



ResultsTop 10%Scoredat Least:

AverageRate:

Top 10%Scoredat Least:

AverageRate:


Accredited OrganizationsMeasure Area Explanation Nationwide StatewideHospital-BasedInpatient PsychiatricServices

This category of evidenced based measures assesses theoverall quality of care given to psychiatric patients.

99% of450 eligiblePatients



2 2










Not displayed


reported.













Assessment of violence risk,substance use disorder,trauma and patient strengthscompleted - Children (1-12years)

This measure reports the number ofchildren age (1-12 years) screenedfor violence risk to self and others,substance and alcohol use,psychological trauma history andpatient strengths. Screening forviolence risk to self determines ifpatients are likely to harmthemselves. Screening for violencerisk to others determines if patientsare likely to harm others. Screeningfor substance and alcohol usedetermines if patients need help fortheir use. Screening forpsychological trauma historydetermines if patients haveexperienced terrible events in theirlives which have left them fearful oranxious and unable to handle theirfeelings. Screening for patientstrengths identifies positive thingssuch as family support, a steady job,housing, etc. which are used to helpthe patient recover.

100% 96% ----3 ----3




AverageRate:


AverageRate:




3

----



2 2










Not displayed


reported.













Assessment of violence risk,substance use disorder,trauma and patient strengthscompleted - Adolescent (13-17years)

This measure reports the number ofadolescent age (13-17 years)screened for violence risk to self andothers, substance and alcohol use,psychological trauma history andpatient strengths. Screening forviolence risk to self determines ifpatients are likely to harmthemselves. Screening for violencerisk to others determines if patientsare likely to harm others. Screeningfor substance and alcohol usedetermines if patients need help fortheir use. Screening forpsychological trauma historydetermines if patients haveexperienced terrible events in theirlives which have left them fearful oranxious and unable to handle theirfeelings. Screening for patientstrengths identifies positive thingssuch as family support, a steady job,housing, etc. which are used to helpthe patient recover.

100% 96% 100% 99%




AverageRate:


AverageRate:







2 2










Not displayed


reported.













Assessment of violence risk,substance use disorder,trauma and patient strengthscompleted - Adult (18-64years)

This measure reports the number ofadults age (18-64 years) screenedfor violence risk to self and others,substance and alcohol use,psychological trauma history andpatient strengths. Screening forviolence risk to self determines ifpatients are likely to harmthemselves. Screening for violencerisk to others determines if patientsare likely to harm others. Screeningfor substance and alcohol usedetermines if patients need help fortheir use. Screening forpsychological trauma historydetermines if patients haveexperienced terrible events in theirlives which have left them fearful oranxious and unable to handle theirfeelings. Screening for patientstrengths identifies positive thingssuch as family support, a steady job,housing, etc. which are used to helpthe patient recover.

100% 95% 100% 99%




AverageRate:


AverageRate:







2 2










Not displayed


reported.













Assessment of violence risk,substance use disorder,trauma and patient strengthscompleted - Older Adult (>= 65years)

This measure reports the number ofolder adult (>= 65 years) screenedfor violence risk to self and others,substance and alcohol use,psychological trauma history andpatient strengths. Screening forviolence risk to self determines ifpatients are likely to harmthemselves. Screening for violencerisk to others determines if patientsare likely to harm others. Screeningfor substance and alcohol usedetermines if patients need help fortheir use. Screening forpsychological trauma historydetermines if patients haveexperienced terrible events in theirlives which have left them fearful oranxious and unable to handle theirfeelings. Screening for patientstrengths identifies positive thingssuch as family support, a steady job,housing, etc. which are used to helpthe patient recover.

100% 95% 100% 98%




AverageRate:


AverageRate:







2 2










Not displayed


reported.













Multiple AntipsychoticMedications at Discharge withAppropriate JustificationOverall Rate

This is a proportion measure. Aproportion measure is a measurewhich shows the number ofoccurrences over the entire groupwithin which the occurrence shouldtake place. The numerator isexpressed as a subset of thedenominator. This measure reportsthe overall number of patientsdischarged on two or moreantipsychotic medications.Antipsychotic medications are agroup of drugs used to treatpsychosis. Psychosis is a mentalillness that markedly interferes with apersons capacity to meet lifeseveryday demands.

100% 63% 100% 71%

Multiple AntipsychoticMedications at Discharge withAppropriate JustificationChildren Age 1 - 12

This measure reports the number ofpatients age 1 through 12 yearsdischarged on two or moreantipsychotic medications for whichthere was an appropriate justification.Antipsychotic medications are agroup of drugs used to treatpsychosis. Psychosis is a mentalillness that markedly interferes with aperson's capacity to meet life'severyday demands. Appropriatejustifications include previousattempts to control psychosis withone antipsychotic medication, a planto reduce the number ofantipsychotic medications to oneantipsychotic medication or theaddition of an antipsychoticmedication when the patient is alsobeing treated with Clozapine.

100% 50% ----3 ----3




AverageRate:


AverageRate:





3

----



2 2










Not displayed


reported.













Multiple AntipsychoticMedications at Discharge withAppropriate JustificationAdolescents Age 13 - 17


100% 48% 100% 77%




AverageRate:


AverageRate:




4

----



2 2










Not displayed


reported.













Multiple AntipsychoticMedications at Discharge withAppropriate JustificationAdults Age 18 - 64


100% 64% 100% 72%




AverageRate:


AverageRate:







2 2










Not displayed


reported.













Multiple AntipsychoticMedications at Discharge withAppropriate Justification OlderAdults Age 65 and Older

This measure reports the number ofpatients age 65 and older dischargedon two or more antipsychoticmedications for which there was anappropriate justification.Antipsychotic medications are agroup of drugs used to treatpsychosis. Psychosis is a mentalillness that markedly interferes with aperson's capacity to meet life'severyday demands. Appropriatejustifications include previousattempts to control psychosis withone antipsychotic medication, a planto reduce the number ofantipsychotic medications to oneantipsychotic medication or theaddition of an antipsychoticmedication when the patient is alsobeing treated with Clozapine.

100% 56% 100% 58%

Hours of Physical RestraintUse per 1000 Patient Hours -Overall Rate

This measure reports the total hourspatients were kept in physicalrestraints for every 1,000 hours ofpatient care. Physical restraint is anymanual method or physical ormechanical device, material, orequipment that immobilizes orreduces the ability of a patient tomove his or her arms, legs, body orhead freely when it is used as arestriction to manage a patient’sbehavior or restrict the patient’sfreedom of movement and is not astandard treatment for the patient’smedical or psychiatric condition.

N/A 0.49 N/A 0.41




AverageRate:


AverageRate:




3

----

0.22(57 Total Hoursin Restraint)



2 2










Not displayed


reported.













Hours of Physical RestraintUse Children Age 1 - 12

This measure reports the number ofhours patients age 1 through 12years were kept in physical restraintsfor every 1,000 hours of patient care.Physical restraint is any manualmethod or physical or mechanicaldevice, material, or equipment thatimmobilizes or reduces the ability ofa patient to move his or her arms,legs, body or head freely when it isused as a restriction to manage apatient’s behavior or restrict thepatient’s freedom of movement andis not a standard treatment for thepatient’s medical or psychiatriccondition.

N/A 0.40 N/A 0.22

Hours of Physical RestraintUse Adolescents Age 13 - 17


N/A 0.28 N/A 0.09




AverageRate:


AverageRate:




3

----




2 2










Not displayed


reported.













Hours of Physical RestraintUse Adults Age 18 - 64


N/A 0.58 N/A 0.52

Hours of Physical RestraintUse Older Adults Age 65 andOlder

This measure reports the number ofhours patients age 65 and older werekept in physical restraints for every1,000 hours of patient care. Physicalrestraint is any manual method orphysical or mechanical device,material, or equipment thatimmobilizes or reduces the ability ofa patient to move his or her arms,legs, body or head freely when it isused as a restriction to manage apatient’s behavior or restrict thepatient’s freedom of movement andis not a standard treatment for thepatient’s medical or psychiatriccondition.

N/A 0.10 N/A 0.07

Hours of Seclusion Use per1000 Patient Hours - OverallRate

This measure reports the total hourspatients were kept in seclusion forevery 1,000 hours of patient care.Seclusion is the involuntaryconfinement of a patient alone in aroom or an area where the patient isphysically prevented from leaving.

N/A 0.42 N/A 0.04




AverageRate:


AverageRate:





3

0.22(6 Total Hoursin Restraint)3

0.00(0 Total Hoursin Seclusion)



2 2










Not displayed


reported.













Hours of Seclusion UseChildren Age 1 - 12

This measure reports the number ofhours patients age 1 through 12years were kept in seclusion forevery 1,000 hours of patient care.Seclusion is the involuntaryconfinement of a patient alone in aroom or an area where the patient isphysically prevented from leaving.

N/A 0.66 N/A 0.17

Hours of Seclusion UseAdolescents Age 13 - 17


N/A 0.22 N/A 0.06

Hours of Seclusion Use AdultsAge 18 - 64


N/A 0.49 N/A 0.03

Hours of Seclusion Use OlderAdults Age 65 and Older

This measure reports the number ofhours patients age 65 and older werekept in seclusion for every 1,000hours of patient care. Seclusion isthe involuntary confinement of apatient alone in a room or an areawhere the patient is physicallyprevented from leaving.

N/A 0.08 N/A 0.01




AverageRate:


AverageRate:




3

----






2 2










Not displayed


reported.













Antenatal Steroids This measure reports the overallnumber of mothers who were at riskof preterm delivery at 24-32 weeksgestation receiving antenatal steroidsprior to delivering preterm newborns.Antenatal steroids are steroids givenbefore birth.

100% 99% 100% 98%

Elective Delivery This measure reports the overallnumber of mothers who had electivevaginal deliveries or electivecesarean sections at equal to andgreater than 37 weeks gestation toless than 39 weeks gestation. Anelective delivery is the delivery of anewborn(s) when the mother was notin active labor or presented withspontaneous ruptured membranesprior to medical induction and/orcesarean section.

0% 2% 0% 2%

Exclusive Breast Milk Feeding This measure reports the overallnumber of newborns who areexclusively breast milk fed during thenewborns entire hospitalization.Exclusive breast milk feeding is whena newborn receives only breast milkand no other liquids or solids exceptfor drops or syrups consisting ofvitamins, minerals, or medicines.

73% 51% 61% 46%




AverageRate:


AverageRate:


Accredited OrganizationsMeasure Area Explanation Nationwide StatewidePerinatal Care This category of evidenced based measures assesses the

care of mothers and newborns.






2 2



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