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Quality Measures

 
  • Quality Measurements as reported on Hospital Compare
  • Posted on 07/08/2022 - Quality data on this website is updated annually.

This report is based on information from Hospital Compare, a website created through the efforts of the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services, along with the Hospital Quality Alliance (HQA). The HQA is a public-private collaboration established to promote reporting on hospital quality of care.

For more extensive quality data, visit the Hospital Compare website, which is updated quarterly.

Natchitoches Regional Medical Center
501 Keyser Avenue
Natchitoches, LA 71457
(318) 214-4200

Timely & Effective Care

Cancer Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
No Data are available for this hospital.

Cataract Surgery Outcome

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
OP-31. Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery N/A 5 N/A 96% 98%

Colonoscopy Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
OP-29. Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients 60   83% 90% 88%

Sepsis Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
SEP-1. Appropriate care for severe sepsis and septic shock 66   67% 57% 56%
SEP-SH-3HR. Septic Shock 3-Hour Bundle 50   90% 82% 81%
SEP-SH-6HR. Septic Shock 6-Hour Bundle 22   64% 83% 77%
SEV_SEP_3HR. Severe Sepsis 3-Hour Bundle 66   88% 78% 78%
SEV_SEP_6HR. Severe Sepsis 6-Hour Bundle 51   98% 89% 90%

Timely Heart Attack Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
OP-2. Fibrinolytic Therapy received within 30 minutes N/A 1 N/A 53% 43%
OP-3b. Median Time to transfer patients for Acute Coronary Intervention N/A 1 N/A 61 minutes 66 minutes

Timely Emergency Department Care

Measure Number of Patients Footnotes Hospital Score National Average State Average
OP-18b. Average time patients spent in the emergency department before being sent home 364   186 minutes 155 minutes 131 minutes
OP-18c. Average (median) time patients spent in the emergency department before leaving from the visit- Psychiatric/Mental Health Patients. 15   232 minutes 254 minutes 230 minutes
OP-22. Percentage of patients who left the emergency department before being seen 17,682   4% 2% 2%
OP-23. Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival 21   81% 71% 70%

Preventive Care

Measure Number of Patients Footnotes Hospital Score National Average State Average
IMM-3. Healthcare workers given influenza vaccination 861   100% 86% 81%

Stroke Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
No Data are available for this hospital.

Blood Clot Prevention and Treatment

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
No Data are available for this hospital.

Pregnancy and Delivery Care

Measure Number of Patients Hospital Footnotes Hospital Score National Average State Average
PC-01. Women who had elective deliveries 1-3 weeks early when not medically necessary 51 2 0% 2% 2%

Survey of Patients' Experiences

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Survey question Measure Percent Measure Percent Measure Percent Star Rating
Nurses communicated well Always 78% Usually 15% Sometimes 7% **
Doctors communicated well Always 82% Usually 12% Sometimes 6% ***
Help received quickly Always 57% Usually 27% Sometimes 16% **
Staff explained medicines Always 57% Usually 15% Sometimes 28% **
Room and bath kept clean Always 71% Usually 16% Sometimes 13% ***
Area quiet at night Always 65% Usually 26% Sometimes 9% ***
Given discharge instructions Yes 83% No 17%   ***
Patient understood care Strongly Agree 46% Agree 46% Disagree 8% **
Overall hospital rating High 64% Medium 26% Low 10% ***
Would recommend hospital Definitely 63% Probably 31% No 6% ***
Summary Star Rating   ***

Readmissions, Complications and Deaths

30-Day Risk Adjusted Mortality Rates

Measure Hospital Predicted Range National Average
Number Patients Mortality Rate from to
CABG N/A N/A N/A N/A 2.9%
Heart Attack N/A N/A N/A N/A 12.4%
Heart Failure 65 10.2% 6.8% 14.6% 11.3%
Pneumonia N/A N/A N/A N/A N/A
COPD 68 9.6% 6.8% 13.4% 8.4%
Stroke N/A N/A N/A N/A 13.6%

30-Day Risk Adjusted Readmission Rates

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
Colonoscopy N/A N/A N/A N/A N/A
CABG N/A N/A N/A N/A 11.9%
Heart Attack N/A N/A N/A N/A 15.0%
Heart Failure 71 20.8% 17.3% 25.0% 21.3%
Pneumonia N/A N/A N/A N/A N/A
COPD 75 19.3% 16.0% 23.7% 19.8%
Hip/Knee Surgery N/A N/A N/A N/A 4.1%
Hospital-wide 349 13.9% 12.4% 15.4% 15.0%

Visit Rates Following OP Procedure

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy N/A N/A N/A N/A N/A
Rate of inpatient admissions for patients receiving outpatient chemotherapy N/A N/A N/A N/A N/A
Ratio of unplanned hospital visits after hospital outpatient surgery 38 1.2% 0.8% 1.8% N/A

Hospital Return Days

Measure Hospital Predicted Range National Average
Number Patients Readmission Rate from to
Heart Attack N/A N/A N/A N/A N/A
Heart Failure 71 34.2% -0.4% 77.2% N/A
Pneumonia 95 -33.0% -51.3% -10.8% N/A

Surgical Complications

Measure Hospital Predicted Range National Average
Number Patients Rate from to
Complications for Hip/Knee Replacements N/A N/A N/A N/A 2.40%
PSI-3. Pressure sores N/A N/A N/A N/A N/A
PSI-4. Death from serious treatable complications after surgery N/A N/A N/A N/A N/A
PSI-6. Collapsed lung due to medical treatment N/A N/A N/A N/A N/A
PSI-8. Broken hip from a fall after surgery N/A N/A N/A N/A N/A
PSI-9. Postoperative Hemorrhage or Hematoma Rate N/A N/A N/A N/A N/A
PSI-10. Postoperative Acute Kidney Injury Rate N/A N/A N/A N/A N/A
PSI-11. Postoperative Respiratory Failure Rate N/A N/A N/A N/A N/A
PSI-12. Serious blood clots after surgery N/A N/A N/A N/A N/A
PSI-13. Blood stream infection after surgery N/A N/A N/A N/A N/A
PSI-14. A wound that splits open after surgery N/A N/A N/A N/A N/A
PSI-15. Accidental cuts and tears from medical treatment N/A N/A N/A N/A N/A
PSI-90. Serious Complications Not Applicable N/A N/A N/A N/A

Healthcare Associated Infections

Measure Hospital Score State Score
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI) N/A 1.309
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI) 0.626 0.650
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon) N/A 0.851
HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy) N/A 1.260
HAI-5-SIR. Methicillin-resistant Staphylococcus aureus (or MRSA) blood infections N/A 1.774
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections) 0.000 0.454

Payment and Value of Care

Use of Medical Imaging

Measure Hospital Footnotes Hospital Score National Average State Average
OP-8. MRI Lumbar Spine for Low Back Pain 1 N/A 45.2% 48.1%
OP-10. Abdomen CT - Use of Contrast Material 31.5% 6.2% 13.7%
OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery 4.8% 3.9% 3.6%
OP-39. Breast Cancer Screening Recall Rates 3.5% 9.4% 7.6%

Medicare Spending Per Beneficiary

Measure Hospital Score National Average State Average
MSPB. Medicare Spending per Beneficiary 1.32 0.99 1.04

Measures of Psychiatric Facilities

Inpatient Psychiatric Facility Quality Reporting (IPFQR)

Measure Hospital Score National Average State Average
HBIPS-2. Hours of physical-restraint use 0.00/1,000 0.30% 0.07%
HBIPS-3. Hours of seclusion 0.00/1,000 0.29% 0.06%
HBIPS-5. Patients discharged on multiple antipsychotic medications with appropriate justification 91.00% 64.00% 68.00%
IMM-2. Influenza immunization 93.00% 79.00% 76.00%
MedCoPsy. Medication Continuation Following Inpatient Psychiatric Discharge N/A 73.10% 75.60%
SMD. Screening for metabolic disorders 98.00 77.00% 78.00%
SUB-2. Alcohol use brief intervention provided or offered N/A 79.00% 87.00%
SUB-2A. Alcohol use brief intervention received N/A 72.00% 74.00%
SUB-3. Alcohol and other drug use disorder treatment provided or offered at discharge 96.00 75.00% 82.00%
SUB-3A. Alcohol and other drug use disorder treatment receieved 44.00 63.00% 62.00%
TOB-2. Tobacco use treatment provided or offered 94.00 80.00% 89.00%
TOB-2A. Tobacco use treatment received 62.00 45.00% 41.00%
TOB-3. Tobacco use treatment provided or offered at discharge 94.00 61.00% 81.00%
TOB-3A. Tobacco use treatment received at discharge 0.00 21.00% 35.00%
TR1. Transition record with specified elements received by discharged patients 97.00 69.00% 82.00%
TR2. Timely transmission of transition record 96.00 60.00% 74.00%
FUH-30. Follow-Up After Hospitalization for Mental Illness within 30 days 63.20% 49.50% 47.70%
FUH-7. Follow-Up After Hospitalization for Mental Illness within 7 days 31.60% 27.90% 30.70%