Reporting Period: October 2011 - September 2012

	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:
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)		100%	98%	100%	99%
	98% of 456 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%	98%	100%	98%
	100% of 65 eligible Patients
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%	96%	100%	96%
	96% of 194 eligible Patients
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 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. 10 - Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement. 11 - There were no eligible patients that met the denominator criteria.