Hospital Performance Reports

The Hospital Performance Report is designed to provide hospital quality information to patients, their families, and health care professionals, so they might be better informed when making decisions about their healthcare. When reviewing the data, please note that the 2009 report contains data from the year 2008.

The report shows how hospitals treat eligible patients admitted with a heart attack, pneumonia, or heart failure or patients having surgery. Patients must receive the correct care and it must be documented by the physician in the record. These measures are based on recognized national standards for diagnosis and treatment. It is important to note that ensuring proper documentation in a specific part of the medical record affects the reportable score. When a recommended course of care is actually provided but is not documented accordingly, the case is not counted as compliant with the process.

The report includes four overall scores for how each hospital treats patients diagnosed with heart attack, pneumonia or heart failure and patients having surgery, as well as scores on the specific interventions that lead to the overall scores. The score for each measure reflects the percentage of eligible patients who received the correct treatment. For example, an 85% rate means that the hospital provided the recommended care for 85% of the eligible patients. The goal for each measure is 100% compliance, so that all patients receive the best care. Patients who should not receive the treatments due to their specific conditions are excluded from the measures.

It’s worth noting that these Core Measures are quality metrics designed to measure processes of care, as opposed to outcomes.The distinction lies in the fact that based upon evidence compiled in medical literature, it is assumed that following the designated processes will lead to better outcomes, and there’s no reason to doubt that. However, it is still possible for a hospital to have outcomes that are equal to or better than other hospitals, even though its process-related Core Measures do not score as high.

At Shore Memorial, we continue to work with the System Board Quality Committee, the Medical Staff Clinical Effectiveness Committee, the Patient Safety Committee, and the Nursing Quality Council, among others, to move continuously toward better systems of care that are accompanied by the documentation needed to demonstrate to ourselves and the public that we meet or exceed the standards of care in the healthcare community.