CHRISTUS Highland Medical Center 1453 East Bert Kouns Shreveport, LA 71105 (318) 681-4500

Timely & Effective Care

• Definitions

Cancer Care

• Collection Periods

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

Cataract Surgery Outcome

• Collection Periods

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

• Collection Periods

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	103		92%	90%	88%

Sepsis Care

• Collection Periods

Measure	Number of Patients	Hospital Footnotes	Hospital Score	National Average	State Average
SEP-1. Appropriate care for severe sepsis and septic shock	73	2	37%	57%	56%
SEP-SH-3HR. Septic Shock 3-Hour Bundle	33	2	70%	82%	81%
SEP-SH-6HR. Septic Shock 6-Hour Bundle	N/A	1, 2, 3	N/A	83%	77%
SEV_SEP_3HR. Severe Sepsis 3-Hour Bundle	73	2	67%	78%	78%
SEV_SEP_6HR. Severe Sepsis 6-Hour Bundle	38	2	79%	89%	90%

Timely Heart Attack Care

• Collection Periods

Measure	Number of Patients	Hospital Footnotes	Hospital Score	National Average	State Average
OP-2. Fibrinolytic Therapy received within 30 minutes	N/A	7	N/A	53%	43%
OP-3b. Median Time to transfer patients for Acute Coronary Intervention	N/A	1, 3	N/A	61 minutes	66 minutes

Timely Emergency Department Care

• Collection Periods

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	390		156 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.	13		262 minutes	254 minutes	230 minutes
OP-22. Percentage of patients who left the emergency department before being seen	32,825		2%	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	N/A	1	N/A	71%	70%

Preventive Care

• Collection Periods

Measure	Number of Patients	Footnotes	Hospital Score	National Average	State Average
IMM-3. Healthcare workers given influenza vaccination	1,458		86%	86%	81%

Stroke Care

• Collection Periods

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

Blood Clot Prevention and Treatment

• Collection Periods

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

Pregnancy and Delivery Care

• Collection Periods

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	33	2	15%	2%	2%

Survey of Patients' Experiences

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

• Collection Periods / Definitions

Survey question	Measure	Percent	Measure	Percent	Measure	Percent	Star Rating
Nurses communicated well	Always	78%	Usually	16%	Sometimes	6%	***
Doctors communicated well	Always	80%	Usually	16%	Sometimes	4%	****
Help received quickly	Always	62%	Usually	24%	Sometimes	14%	***
Staff explained medicines	Always	63%	Usually	12%	Sometimes	25%	**
Room and bath kept clean	Always	72%	Usually	20%	Sometimes	8%	****
Area quiet at night	Always	67%	Usually	25%	Sometimes	8%	****
Given discharge instructions	Yes	86%	No	14%			***
Patient understood care	Strongly Agree	55%	Agree	39%	Disagree	6%	***
Overall hospital rating	High	75%	Medium	16%	Low	9%	***
Would recommend hospital	Definitely	77%	Probably	17%	No	6%	****
Summary Star Rating							***

Readmissions, Complications and Deaths

• Collection Periods / Definitions

30-Day Risk Adjusted Mortality Rates

Measure	Hospital		Predicted Range		National Average
	Number Patients	Mortality Rate	from	to
CABG	168	2.8%	1.5%	5.2%	2.9%
Heart Attack	176	11.7%	9.1%	14.7%	12.4%
Heart Failure	462	11.4%	9.0%	14.2%	11.3%
Pneumonia	N/A	N/A	N/A	N/A	N/A
COPD	116	9.1%	6.4%	12.6%	8.4%
Stroke	99	13.2%	9.5%	18.3%	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	166	16.2%	12.5%	20.9%	11.9%
Heart Attack	195	15.2%	12.5%	18.3%	15.0%
Heart Failure	560	19.3%	16.8%	21.9%	21.3%
Pneumonia	N/A	N/A	N/A	N/A	N/A
COPD	121	19.3%	16.0%	23.2%	19.8%
Hip/Knee Surgery	127	4.1%	2.8%	5.9%	4.1%
Hospital-wide	2,169	14.2%	13.2%	15.3%	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	140	1.1%	0.7%	1.6%	N/A

Hospital Return Days

Measure	Hospital		Predicted Range		National Average
	Number Patients	Readmission Rate	from	to
Heart Attack	195	-2.9%	-18.0%	15.1%	N/A
Heart Failure	560	-5.5%	-20.6%	11.0%	N/A
Pneumonia	279	12.8%	-6.1%	34.2%	N/A

Surgical Complications

• Collection Periods

Measure	Hospital		Predicted Range		National Average
	Number Patients	Rate	from	to
Complications for Hip/Knee Replacements	132	2.90%	1.70%	4.90%	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

• Collection Periods

Measure	Hospital Score	State Score
HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI)	2.105	1.309
HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI)	1.452	0.650
HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon)	0.778	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	3.859	1.774
HAI-6-SIR. Clostridium difficile (or C.diff.) Infections (intestinal infections)	0.603	0.454

Payment and Value of Care

• Definitions

Use of Medical Imaging

• Collection Periods

Measure	Hospital Footnotes	Hospital Score	National Average	State Average
OP-8. MRI Lumbar Spine for Low Back Pain		54.4%	45.2%	48.1%
OP-10. Abdomen CT - Use of Contrast Material		10.3%	6.2%	13.7%
OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery	1	N/A	3.9%	3.6%
OP-39. Breast Cancer Screening Recall Rates		6.7%	9.4%	7.6%

Medicare Spending Per Beneficiary

• Collection Periods

Measure	Hospital Score	National Average	State Average
MSPB. Medicare Spending per Beneficiary	1.01	0.99	1.04

Measures of Psychiatric Facilities

Inpatient Psychiatric Facility Quality Reporting (IPFQR)

• Collection Periods / Definitions

Measure	Hospital Score	National Average	State Average
No Data are available for this hospital.