The Joint Commission
Quality Check


  Symbol Key
This organization achieved the best possible results
This organization’s performance is above the target range/value.
This organization’s performance is similar to the target range/value.
This organization’s performance is below the target range/value.
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Quality Report
Hospital
OSF Saint Francis Medical Center
Org ID: 7410

National Quality Improvement Goals: Surgical Care Improvement Project (SCIP)

Reporting Period: July 2012 - June 2013

  Compared to other Joint Commission Accredited Organizations
Measure Area
Nationwide Statewide
SCIP - Infection Prevention
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This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.

  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:
Patients having a surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
1101 eligible Patients7
Patients having surgery who received the appropriate medicine (antibiotic) which is shown to be effective for the type of surgery performed.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
1101 eligible Patients7
Patients who had surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 98% 100% 98%
99% of
1073 eligible Patients7
 
Patients Having Blood Vessel Surgery*
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(See Quarterly Results)
This organization’s performance is similar to the target range/value.
100% 98% 100% 98%
98% of
141 eligible Patients7
Patients having blood vessel surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.*
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(See Quarterly Results)
This organization achieved the best possible results.
100% 98% 100% 97%
100% of
48 eligible Patients7
Patients having blood vessel surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.*
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(See Quarterly Results)
This organization achieved the best possible results.
100% 99% 100% 100%
100% of
48 eligible Patients7
Patients who had blood vessel surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.*
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(See Quarterly Results)
This organization’s performance is similar to the target range/value.
100% 96% 100% 97%
93% of
45 eligible Patients7
 
Patients Having Colon/Large Intestine Surgery*
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(See Quarterly Results)
This organization’s performance is similar to the target range/value.
100% 96% 100% 97%
96% of
284 eligible Patients7
Patients having colon/large intestine surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut. *
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(See Quarterly Results)
This organization’s performance is similar to the target range/value.
100% 98% 100% 98%
94% of
96 eligible Patients7
Patients having colon/large intestine surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.*
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(See Quarterly Results)
This organization’s performance is similar to the target range/value.
100% 96% 100% 96%
95% of
96 eligible Patients7
Patients who had colon/large intestine surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.*
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(See Quarterly Results)
This organization’s performance is similar to the target range/value.
100% 96% 100% 97%
99% of
92 eligible Patients7
 
Patients Having Coronary Artery Bypass Graft Surgery*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
100% of
305 eligible Patients7
Patients having coronary artery bypass graft surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.*
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(See Quarterly Results)
This organization achieved the best possible results.
100% 99% 100% 99%
100% of
102 eligible Patients7
Patients having coronary artery bypass graft surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.*
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(See Quarterly Results)
This organization achieved the best possible results.
100% 100% 100% 100%
100% of
102 eligible Patients7
Patients who had coronary artery bypass graft surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 48 hours after the surgery ended.*
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(See Quarterly Results)
This organization achieved the best possible results.
100% 99% 100% 98%
100% of
101 eligible Patients7
 
Patients Having Hip Joint Replacement Surgery*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
658 eligible Patients7
Patients having hip joint replacement surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
221 eligible Patients7
Patients having hip joint replacement surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 100% 100% 100%
99% of
221 eligible Patients7
Patients who had hip joint replacement surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 98% 100% 98%
99% of
216 eligible Patients7
 
Patients Having a Hysterectomy*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 98% 100% 98%
98% of
435 eligible Patients7
Patients having hysterectomy surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
146 eligible Patients7
Patients having hysterectomy surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 98% 100% 98%
98% of
146 eligible Patients7
Patients who had hysterectomy surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.*
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(See Quarterly Results)
This organization’s performance is similar to the target range/value.
100% 98% 100% 98%
97% of
143 eligible Patients7
 
Patients Having Knee Joint Replacement Surgery*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
1042 eligible Patients7
Patients having knee joint replacement surgery who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
349 eligible Patients7
Patients having knee joint replacement surgery who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.*
Read More


(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 100% 100% 100%
99% of
349 eligible Patients7
Patients who had knee joint replacement surgery and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 24 hours after the surgery ended.*
Read More


(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 98% 100% 99%
99% of
344 eligible Patients7
 
Patients Having Open Heart Surgery other than Coronary Artery Bypass Graft*
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 99% 100% 99%
99% of
410 eligible Patients7
Patients having open heart surgery other than coronary artery bypass graft who received medicine to prevent infection (an antibiotic) within one hour before the skin was surgically cut.*
Read More


(See Quarterly Results)
This organization achieved the best possible results.
100% 99% 100% 99%
100% of
139 eligible Patients7
Patients having open heart surgery other than coronary artery bypass graft who received the appropriate medicine (antibiotic) which is shown to be effective for this type of surgery.*
Read More


(See Quarterly Results)
This organization achieved the best possible results.
100% 100% 100% 100%
100% of
139 eligible Patients7
Patients who had open heart surgery other than coronary artery bypass graft and received appropriate medicine that prevents infection (antibiotic) and the antibiotic was stopped within 48 hours after the surgery ended.*
Read More


(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 98% 100% 99%
99% of
132 eligible Patients7
 
Heart surgery patients with controlled blood sugar after surgery.
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 97% 100% 97%
99% of
271 eligible Patients7
Surgery patients with proper hair removal.
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(See Quarterly Results)
This organization achieved the best possible results.
100% 100% 100% 100%
100% of
1467 eligible Patients7
Urinary Catheter Removed
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(See Quarterly Results)
This organization’s performance is above the target range/value.
100% 97% 100% 98%
98% of
903 eligible Patients7
National Quality Forum The Joint Commission only reports measures endorsed by the National Quality Forum.  
* 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.


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