Performance At A Glance
Delnor applies an objective statistical test to compare its performance to the National Average. Delnor uses a 95% Confidence Interval which functions to eliminate random variation. If a Delnor score falls within the Confidence Interval of the National Average, we consider our results to be at or near the National Average (yellow), even if our numerical score may appear to be higher. If our performance is higher or lower in a statistically significant way, we color code our performance as better (green) or worse (red) than the National Average.
Delnor strives to perform in the top tenth percentile, meaning better than 90% or more of all other hospitals.
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Green = Statistically better than the National Average
Yellow = At or near the National Average
Red = Worse than the National Average
Grey = No National Average
Summary view of Delnor’s performance in the 23 Hospital Compare Clinical Measures: 21 of 23 measures are above the National Average at a statistically significant level.
9%91%
*Based on 23 clinical measures for the period January 2009 – December 2009.
Care for Heart Attack | Care for Heart Failure
Care for Pneumonia | Surgical Care
Care For Heart Attack
A heart attack (also called an AMI or acute myocardial infarction) happens when the arteries leading to the heart become blocked and the blood supply is slowed or stopped. These quality measures show some of the standards of care provided, if appropriate, to someone who has a heart attack.
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| Care For Heart Attack |
| Desired Performance |
 |
National Average |
Top Hospitals |
| Heart Attack Patients Given Aspirin at Arrival |
| High is good |
99%* |
95% |
100% |
| Heart Attack Patients Given Aspirin at Discharge |
| High is good |
100%* |
94% |
100% |
| Heart Attack Patients Given Beta Blocker at Discharge |
| High is good |
100%* |
94% |
100% |
Heart Attack Patients Given ACE Inhibitor
or ARB for Left Ventricular Systolic Dysfunction (LVSD) |
| High is good |
100% ¹* |
93% |
100% |
| Heart Attack Patients Given PCI Within 90 Minutes of Arrival |
| High is good |
94% |
84% |
100% |
| Heart Attack Patients Given Smoking Cessation Advice |
| High is good |
100*% |
97% |
100% |
| In cases where Delnor is not achieving target, we are aggressively taking action to improve results. |
¹ The number of cases is too small (n<25) for purposes of reliably predicting hospital performance.
* Equal to or higher than top 10% of all hospitals
Care For Heart Failure
Heart failure is a weakening of the heart’s pumping power. With heart failure, your body doesn’t get enough oxygen and nutrients to meet its needs. These quality measures show some of the standards of care provided, if appropriate, to someone who has heart failure.
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| Care For Heart Failure |
| Desired Performance |
|
National Average |
Top Hospitals |
| Heart Failure Patients Given Discharge Instructions |
| High is good |
85% |
80% |
100% |
Heart Failure Patients Given ACE Inhibitor
or ARB for Left Ventricular Systolic Dysfunction (LVSD) |
| High is good |
100%* |
90% |
100% |
| Heart Failure Patients Given Smoking Cessation Advice |
| High is good |
100%* |
93% |
100% |
Heart Failure Patients Given an Evaluation
of Left Ventricular Systolic (LVS) Function |
| High is good |
100%* |
90% |
100% |
| In cases where Delnor is not achieving target, we are aggressively taking action to improve results. |
¹ The number of cases is too small (n<25) for purposes of reliably predicting hospital performance.
* Equal to or higher than top 10% of all hospitals
Care For Pneumonia
Pneumonia is a serious lung infection that causes difficulty breathing, fever, cough and fatigue. These quality measures show some of the recommended treatments for pneumonia.
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| Care For Pneumonia |
| Desired Performance |
|
National Average |
Top Hospitals |
| Pneumonia Patients Assessed and Given Influenza Vaccination |
| High is good |
98% |
86% |
100% |
| Pneumonia Patients Assessed and Given Pneumococcal Vaccination |
| High is good |
100% * |
88% |
100% |
| Pneumonia Patients Given Smoking Cessation Advice |
| High is good |
100% * |
91% |
100% |
| Pneumonia Patients Given The Most Appropriate Initial Antibiotic(s) |
| High is good |
97% |
89% |
99% |
Pneumonia Patients Given Initial Antibiotic(s)
Within 6 Hours After Arrival |
| High is good |
99% |
94% |
100% |
Pneumonia Patients Whose Blood Culture
was Performed in the Emergency Department
Prior to the Initial Antibiotic Received in Hospital |
| High is good |
100%* |
93% |
100% |
| In cases where Delnor is not achieving target, we are aggressively taking action to improve results. |
¹ The number of cases is too small (n<25) for purposes of reliably predicting hospital performance.
* Equal to or higher than top 10% of all hospitals
Surgical Care
Hospitals can reduce the risk of wound infection after surgery by making sure patients get the right medicines at the right time on the day of their surgery. These quality measures show some of the standards of care.
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| Surgical Care |
| Desired Performance |
|
National Average |
Top Hospitals |
Surgery Patients Whose Preventative Antibiotic(s)
are Stopped Within 24 Hours After Surgery |
| High is good |
97% |
88% |
100% |
Surgery Patients Who Received the Appropriate
Preventative Antibiotic(s) for Their Surgery |
| High is good |
97% |
95% |
100% |
Surgery Patients Who Received
Preventative Antibiotic(s) One Hour Before Incision |
| High is good |
98% |
93% |
100% |
| Surgery Patients With Recommended Post Surgical Clot Prevention |
| High is good |
97% |
89% |
100% |
Surgery Patients who received treatment to Prevent Blood Clots
within 24 hours prior to surgery or 24 hours after surgery |
| High is good |
97% |
88% |
100% |
| Surgery Patients with appropriate hair removal |
| High is good |
100% * |
98% |
100% |
Surgery Patients on Beta Blocker Therapy Prior to Admission Who
Received a Beta Blocker During the Perioperative Period |
| High is good |
96% |
87% |
100% |
| In cases where Delnor is not achieving target, we are aggressively taking action to improve results. |
¹ The number of cases is too small (n<25) for purposes of reliably predicting hospital performance.
* Equal to or higher than top 10% of all hospitals
Why is this Important? Aspirin can help keep blood clots from forming and dissolve blood clots that can cause heart attacks. Chewing an aspirin as soon as symptoms of a heart attack begin may help reduce the severity of the attack.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Following a heart attack, continued use of aspirin may help reduce the risk of another heart attack. Talk to a healthcare provider before using aspirin on a regular basis to make sure it’s safe for you.
Source: Hospital Compare
Dates of Coverage:January 2009 – December 2009
Why is this Important? Beta blockers are a type of medicine that is used to lower blood pressure, treat chest pain (angina) and heart failure, and to help prevent a heart attack. Most heart attack patients should be given a beta blocker within 24 hours of arriving at the hospital.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Beta blockers relieve the stress of your heart by slowing the heart rate and reducing the force with which your heart muscles contract to pump blood. If you have a heart attack, you should get a prescription for a beta blocker before you leave the hospital.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? ACE (angiotensin converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) are medicines used to treat patients with heart failure and are particularly beneficial for those patients with heart failure and decreased function of the left side of the heart. They can also reduce the risk of death from future heart attacks.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Percutaneous Coronary Interventions (PCI) are procedures that are among the most effective ways to open blocked blood vessels and help prevent further heart muscle damage. These procedures all involve a catheter (a flexible tube) that is inserted and guided through the blood vessels to the blockage.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Smoking increases your risk for developing blood clots and heart disease that can result in a heart attack, heart failure or stroke. Smoking is also linked to lung disease and cancer, and can cause premature death. Quitting may help prevent another heart attack.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Heart failure is a chronic condition. It results in symptoms such as shortness of breath, dizziness and fatigue. Before you leave the hospital, the staff at the hospital should provide you with information to help you manage the symptoms after you get home.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? ACE (angiotensin converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) are medicines used to treat patients with heart failure and are particularly beneficial for those patients with heart failure and decreased function of the left side of the heart.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Smoking increases your risk for developing blood clots and heart disease that can result in a heart attack, heart failure or stroke. Smoking is also linked to lung disease and cancer, and can cause premature death. Quitting may help prevent another heart attack.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? The proper treatment for heart failure depends on what area of your heart is affected. An important test is to check how your heart is pumping, called an “evaluation of the left ventricular systolic function.”
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Pneumonia can lower the oxygen in your blood because the air spaces in your lungs fill with mucus. It is important that the amount of oxygen in your blood be measured within 24 hours of arriving at the hospital to see if you need oxygen therapy.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Hospitals should check to make sure that pneumonia patients, particularly those who are age 50 or older, get a flu shot during flu season to protect them from another lung infection and to help prevent the spread of influenza.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? The pneumococcal vaccine may help you prevent, or lower the risk of complications of pneumonia caused by bacteria. It may also help you prevent future infections.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Smoking damages your lungs and makes it hard to breathe. Smoking increases your risk for developing blood clots and heart disease that can result in a heart attack, heart failure or stroke. Smoking increases your chances of getting pneumonia. Quitting may reduce your chance of getting pneumonia again.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Pneumonia is a lung infection that is usually caused by bacteria or a virus. If pneumonia is caused by bacteria, hospitals will treat the infection with antibiotics. Different bacteria are treated with different antibiotics.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Antibiotics are used to treat adults with pneumonia caused by bacteria. Early treatment with antibiotics can cure bacterial pneumonia and reduce the possibility of complications.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Different types of bacteria can cause pneumonia. A blood culture is a test that can help your healthcare provider identify which bacteria may have caused your pneumonia, and which antibiotic should be prescribed.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Antibiotics are medicines to prevent and treat infections. Taking these antibiotics for more than 24 hours after routine surgery is usually not necessary and can increase the risk of side effects and antibiotic resistance. For certain surgeries antibiotics may be needed for a longer time.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Infections continue to be the main preventable complication of most surgical procedures. By following the standard guidelines for timing and giving you the correct antibiotic drug, hospitals can reduce your risk of getting a wound infection after surgery.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Research shows that surgery patients who get antibiotics within the hour before their operation are less likely to get wound infections. Getting an antibiotic earlier, or after surgery begins, is not as effective.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? VTE (clot formation) is one of the most common postoperative complications. Prophylaxis (preventive measures) is the most effective strategy to reduce morbidity and mortality from clot formation. The frequency of deep vein clots and clots in the lungs is related to the type and duration of surgery, patient risk factors like smoking, obesity, heart disease and others, duration and extent of immobilization after surgery and the use or non use of prophylaxis. Depending on the type of surgery the method of prophylaxis may vary from anticoagulation drugs like heparin or clot factor inhibitors, to devices like compression stockings or intermittent pneumatic compression devices applied to the legs or feet. Resource for VTE Specification Manual for National Hospital Quality Measures
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Timing of prophylaxis is based on the type of procedure, prophylaxis selection and the physician’s clinical judgment regarding the patient risk factors. The 24 hour pre- and post-procedure time frame was recommended by a Technical Expert Panel to establish a timeframe that would encompass most procedures.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Why is this Important? Beta blockers are a medicine that is used to lower blood pressure, treat chest pain and heart failure, and prevent heart attack. There is benefit to continuing this drug during the peri-operative period.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
Better than the National Average at a statistically significant level. (95% Confidence Level)
Within the statistical confidence interval of the National Average, meaning room for improvement.
Worse than the National Average at a statistically significant level. Delnor is working aggressively to improve.
In this photo:
Tina McClain
R.N, BHSA, Quality Specialist
Fran Sykes
BSN, RN, Quality Specialist
Stacy Knutson
RN, Quality Specialist
Why is this Important? Clipping hair rather than shaving with a razor is less likely to cause skin abrasions that allow bacteria to enter.
Source: Hospital Compare
Dates of Coverage: January 2009 – December 2009
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