Reporting Period: January 2009 - December 2009

	Compared to other Joint Commission Accredited Organizations
Measure Area	Nationwide	Statewide
Pneumonia Care Read More Close Pneumonia Care This category of evidence based measures assesses the overall quality of care provided to Pneumonia patients.

	Compared to other Joint Commission Accredited Organizations
	Nationwide			Statewide
Measure	Hospital Results	Top 10% Scored at Least:	Average Rate:	Top 10% Scored at Least:	Average Rate:
Adult smoking cessation advice/counseling* Read More Close Adult smoking cessation advice/counseling* Pneumonia patients who are given advice about stopping smoking while they are in the hospital. This measure reports what percent of adult pneumonia patients are provided advice and/or counseling to quit smoking. Smoking harms the heart, lungs and blood vessels and makes existing disease worse. Limitations of measure use - see Accreditation Quality Report User Guide. (See Quarterly Results)		100%	98%	100%	99%
	100% of 48 eligible Patients
Blood cultures for pneumonia patients admitted through the Emergency Department.* Read More Close Blood cultures for pneumonia patients admitted through the Emergency Department.* Pneumonia patients who were admitted through the Emergency Department who had a blood test in the Emergency Department for the presence of bacteria in their blood. Before antibiotics are given, blood samples are taken to test for the type of infection. This measure reports the percent of pneumonia patients admitted through the Emergency Department who received this test before antibiotics were given. (See Quarterly Results)		99%	95%	99%	95%
	99% of 106 eligible Patients
Blood cultures for pneumonia patients in intensive care units. Read More Close Blood cultures for pneumonia patients in intensive care units. Pneumonia patients cared for in an intensive care unit that had a blood test for the presence of bacteria in their blood within 24 hours of hospital arrival. This measure reports the percent of pneumonia patients in intensive care units who had a blood culture within 24 hours prior to or after hospital arrival. (See Quarterly Results)		100%	96%	100%	96%
	90% of 30 eligible Patients
Initial antibiotic received within 6 hours of hospital arrival* Read More Close Initial antibiotic received within 6 hours of hospital arrival* Pneumonia patients who are given an antibiotic within 6 hours of arriving at the hospital. This measure reports the percent of adult pneumonia patients who are given an antibiotic within 6 hours of arriving at the hospital. Limitations of measure use - see Accreditation Quality Report User Guide. (See Quarterly Results)		99%	95%	100%	95%
	100% of 102 eligible Patients
Initial antibiotic selection for CAP in immunocompetent – ICU patient* Read More Close Initial antibiotic selection for CAP in immunocompetent – ICU patient* Patients in intensive care units who have community-acquired pneumonia who received the appropriate medicine (antibiotic) that has been shown to be effective for community-acquired pneumonia. This measure reports how often patients in intensive care units with community-acquired pneumonia were given the correct antibiotic within 24 hours of hospital arrival, based on recommendations from written guidelines, for the treatment of pneumonia. (See Quarterly Results)	3	100%	68%	91%	64%
	86% of 7 eligible Patients3
Initial antibiotic selection for CAP in immunocompetent – non ICU patient* Read More Close Initial antibiotic selection for CAP in immunocompetent – non ICU patient* Patients not in intensive care units who have community-acquired pneumonia who received the appropriate medicine (antibiotic) that has been shown to be effective for community-acquired pneumonia. This measure reports how often patients with community-acquired pneumonia not cared for in intensive care units, were given the correct antibiotic within 24 hours of hospital arrival, based on recommendations from written guidelines, for the treatment of pneumonia. (See Quarterly Results)		100%	95%	100%	95%
	100% of 61 eligible Patients
Pneumococcal vaccination* Read More Close Pneumococcal vaccination* Pneumonia vaccination. This measure reports how many patients 65 years and older were screened and vaccinated to prevent pneumonia. (See Quarterly Results)		100%	93%	100%	94%
	100% of 90 eligible Patients
Pneumonia Seasonal Measure Reporting Period: October 2008 - March 2009
Influenza vaccination Read More Close Influenza vaccination Pneumonia patients in the hospital during flu season (October through March) who were given the influenza vaccination prior to leaving the hospital. This measure reports how often pneumonia patients in the hospital during the flu season were given flu vaccine if needed, prior to leaving the hospital. (See Quarterly Results)		99%	89%	99%	90%
	98% of 90 eligible Patients
Center for Medicare and Medicaid (CMS) Hospital 30-Day Risk Adjusted Death (Mortality) compared to U.S. National Rate The rates displayed in this table are from data reported for discharges July 2005 through June 2008 Last Updated: March 18, 2010 The U.S. National 30-day Death Rate from Pneumonia = 12%   Better Than U.S. National Rate (Adjusted mortality is lower than U.S. rate) No Different Than U.S. National Rate (Adjusted mortality is about the same as U.S. rate or difference is uncertain) Worse Than U.S. National Rate (Adjusted mortality is higher than U.S. Rate) 30-Day Death (Mortality) Rates from Pneumonia   (See Rate Details)   Out of 4814 hospitals in U.S. 253 hospitals in the U.S. Better than U.S. National Rate 3934 hospitals in the U.S. No different than U.S. National Rate 284 hospitals in the U.S. Worse than U.S. National Rate 343 hospitals in the United States did not have enough cases to reliably tell how well they are performing Out of 113 hospitals in North carolina 2 hospitals in North carolina Better than U.S. National Rate 95 hospitals in North carolina No different than U.S. National Rate 10 hospitals in North carolina Worse than U.S. National Rate 6 hospitals in the United States did not have enough cases to reliably tell how well they are performing For technical information on 30 Day Risk Adjusted Mortality measures read more.
Center for Medicare and Medicaid (CMS) Hospital 30 Day Rate of Readmission compared to U.S. National Rate The rates displayed in this table are from data reported for discharges July 2005 through June 2008 Last Updated: March 18, 2010 The U.S. Rate for Readmissions for Pneumonia Patients = 18%   Better Than U.S. National Rate (Adjusted readmissions are lower than U.S. rate) No Different Than U.S. National Rate (Adjusted readmissions are about the same as U.S. rate or difference is uncertain) Worse Than U.S. National Rate (Adjusted readmissions are higher than U.S. Rate) 30 Day Hospital Readmission Rates for Pneumonia Patients   (See Rate Details)   Out of 4834 hospitals in U.S. 88 hospitals in the U.S. Better than U.S. National Rate 4199 hospitals in the U.S. No different than U.S. National Rate 198 hospitals in the U.S. Worse than U.S. National Rate 349 hospitals in the United States did not have enough cases to reliably tell how well they are performing Out of 112 hospitals in North carolina 0 hospitals in North carolina Better than U.S. National Rate 104 hospitals in North carolina No different than U.S. National Rate 3 hospitals in North carolina Worse than U.S. National Rate 5 hospitals in the United States did not have enough cases to reliably tell how well they are performing For technical information on Hospital Readmission Rates read more.
The Joint Commission only reports measures endorsed by the National Quality Forum.   * This information is part of the Hospital Quality Alliance. This information can also be viewed at www.hospitalcompare.hhs.gov. ---- Null value or data not displayed. 1 - The measure or measure set was not reported. 2 - The measure set does not have an overall result. 3 - The number of patients is not enough for comparison purposes. 4 - The measure meets the Privacy Disclosure Threshold rule. 5 - The organization scored above 90% but was below most other organizations. 6 - The measure results are not statistically valid. 7 - The measure results are based on a sample of patients. 8 - The number of months with measure data is below the reporting requirement. 9 - The measure results are temporarily suppressed pending resubmission of updated data.