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OUR REPORT CARD

Hanover Hospital is pleased to provide you with information that may assist you in making an informed decision about your healthcare. We believe that it is every individual's right to have transparent access to performance indicators for any healthcare facility in which they may seek care.

Last updated: 2001.  We are in the process of updating and new figures will be released 2008.

Measures of Community Health

• Death Rates and Causes of Death

• Tobacco Use

• Activity, Diet and Obesity

• Alcohol and Other Drugs

• Infant Health

Measures of Clinical Performance

• Primary Care Management

• Treating Heart Attacks

• Treating Congestive Heart Failure

• Treating Pneumonia

Surgical Infection

Patient Safety

Accreditation/Licensing Compliance

Measures of Community Health

Last Updated: December 2005
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Last Updated: December 2005
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Last Updated: December 2005
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Last Updated: December 2005
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Last Updated: December 2005

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Measures of Clinical Performance

Last Updated: December 2005

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Treating Heart Attacks (Myocardial Infarction)
When the blood flow in the arteries to the heart is completely blocked, part of the heart muscle dies causing an acute myocardial infarction, commonly referred to as a heart attack.

Research identified the following six indicators to be the key components of performance in treating heart attacks. A comparison of Hanover Hospital Performance to both Pennsylvania and national averages follows.

+   Quarter 3 (2007) Data
++ Quarter 2 (2007) Data

Why these indicators matter:

• Treatment with aspirin within 24 hours of admission and at discharge: Aspirin is an effective, inexpensive and safe treatment for heart attack. Aspirin therapy reduces short-term mortality in patients with suspected heart attack by 23%, although it should not be given to patients with certain conditions (e.g. hemorrhagic stroke, gastrointestinal bleeding).
  
• Treatment with beta blockers upon admission and at discharge:
  Beta-blocker therapy can reduce post-heart attack mortality by as much as 25% by helping to reduce the workload of the heart.
  
• ACE Inhibitor prescribed at discharge:
  ACE Inhibitors are used to treat high blood pressure and reduce the workload of the heart following a heart attack. ACE Inhibitors can significantly reduce post-heart attack mortality.
  
• MI: Smoking cessation advice:
  Smokers with coronary artery disease who stop smoking have a better prognosis than those who keep smoking; at the time of a heart attack, smokers are most responsive to advice about quitting smoking.

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Treating Congestive Heart Failure (CHF)
Heart failure is a chronic disease that occurs when the heart muscle has been damaged and can no longer effectively pump blood to the rest of the body.

Research identified the following indicators to be the key components of performance in treating CHF. A comparison of Hanover Hospital performance to both Pennsylvania and national averages follows.

+   Quarter 3 (2007) Data

++ Quarter 2 (2007) Data

Why these indicators matter:

• ACE inhibitor prescribed at discharge:
  ACE inhibitors are used to treat high blood pressure and reduce the workload of the heart in patients with congestive heart failure. As such, ACE inhibitors can significantly reduce mortality rates.
  
• Evaluation of left ventricular ejection fraction via echocardiogram:
  Performing an echocardiogram allows practitioners to see how well the heart is contracting and pumping blood. This diagnostic information is used to drive the overall treatment of a patient.
  
• CHF: Smoking cessation advice:
  Smokers with heart failure disease who stop smoking have a better prognosis than those who keep smoking; at the time of exacerbation, smokers are most responsive to advice about quitting smoking.

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Treating Pneumonia
There are two kinds of pneumonia – viral pneumonia and bacterial pneumonia. Bacterial pneumonia is the most serious and is a common cause of hospitalization and death among older people.

Research identified the following indicators to be the key components of performance in treating pneumonia. A comparison of Hanover Hospital performance to both Pennsylvania and national averages follows.

+   Quarter 2 (2007) Data

++ December (2006) Data

Why these indicators matter:

• Antibiotics given within 8 hours of hospitalization:
  Administering antibiotics to patients diagnosed with pneumonia within 8 hours of hospitalization lowers the 30-day mortality rate by 15%.
  
• Flu immunization every year:
  Annual flu vaccination of all people 65 and older and those at risk of exposure who might pass it on to the elderly is recommended to prevent influenza and/or the exacerbation of influenza symptoms which could lead to pneumonia.
  
• Blood cultures:
  Current guidelines recommend blood cultures to help identify bacterial pneumonia versus viral pneumonia.
  
• Oxygenation assessment:
  Hypoxemia (low oxygen) is a known factor for poor outcomes in patients with pneumonia, and supplemental oxygen has been shown to decrease mortality in patients with pneumonia.
  
• Pneumococcal vaccine:
  Pneumococcal vaccination is indicated for persons 65 years of age and older. In the United States today, vaccine coverage is suboptimal; hospitalization, especially for pneumonia, is associated with high risk of subsequent severe pneumococcal disease.
  
• Smoking advice/counseling:
  Smokers with pneumonia disease who stop smoking have a better prognosis than those who keep smoking; at the time of hospitalization, smokers are most responsive to advice about quitting smoking.

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Surgical Infection

Surgical infections affect 2-5% of the 16 million patients undergoing surgical procedures each year in acute care hospitals. These infections may lead to a significant increase in complications and death. Hanover Hospital’s infection control program is designed to reduce the risk of infections in the hospital.

+   Quarter 3 (2007) Data

++ Quarter 2 (2007) Data

Why these indicators matter:

• Surgical infection rate per 100 procedures:
  We measure the overall infection rate to assure our rate remains low. This gives us indications of any changes in the rate that might require changes in the system or process.

• Antibiotic given within 1 hour of incision:
  Timely administration of antibiotics significantly reduces the risk of an infection after surgery.

• Appropriate antibiotic:
  The type of procedure and the assessment of the procedure determine the appropriate antibiotic. The use of appropriate antibiotics also significantly reduces the risk of an infection after surgery.

• A goal of prophylaxis with antibiotics is to provide benefit to patient with as little risk as possible.  Administration of antibiotics for more than a few hours after the incision is closed offers no additional benefit to the surgical patient.  Prolonged administration increases the risk of Clostridium difficile infection and the development of antimicrobial resistant pathogens.

What are we doing to improve:

Our current data show compliance worse than the state or nation in heart attack, heart failure and pneumonia.  In heart attack, we need to improve our compliance in the administration of aspirin within 24 hours of admission and discharge, and the use of beta blockers at discharge.  In heart failure, we need to improve the use of ACE inhibitor at discharge and in pneumonia, we need to improve the time to antibiotics and our door to drug time.

The clinical staff continually review the measures of clinical performance and develop plans for improvement.  Statistical methods are used to determine specific areas to concentrateon and to measure our compliance over time.  Standing orders and protocols are being developed to standardize orders to improve compliance.

Our goal is to have all the clinical performance measures at or above 90% compliance.

Patient Safety

We hope you do not need hospitalization, but if you do we want to make your stay with us as comfortable, and safe as possible. We encourage you to become a member of your own healthcare team. Many medical advances are the result of new technology. However, this also results in a more complex system and increases the potential for errors to occur. Be sure to talk to your doctor, ask questions, listen, and make certain you understand the answers. Tips to Safer Health Care:

• Be an active member of your healthcare team
  
• Make sure that your doctors know about everything that you are taking, including prescription, over the counter medicines and dietary supplements
  
• When your doctor writes you a prescription, make sure that you can read it

• Ask for written information about your medicines in terms that you can understand – both when they are prescribed and when you receive them

• If you have any questions about the directions on your medicine labels, ASK

• Ask your pharmacist for the best device to measure your liquid medicine and ask how to use it

• If you have a choice, choose a hospital at which many patients have had the procedure or surgery you need

• If you are in a hospital, ask all healthcare workers who have direct contact whether they have washed their hands

• When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will use at home

• If you are having surgery, make sure that you, your doctor and your surgeon all agree and are clear on exactly what will be done

• Speak up if you have any questions or concerns

• Make sure that someone, such as your personal doctor, is in charge of your care

• Make sure that all health professionals involved in your care have all of the important information about you

• Ask a family member or friend to be there with you and to be your advocate (someone who can help get things done and speak up for you if you can’t)

• Know that “more” is not always better

• If you have a test done, don’t assume that “no news is good news”

• Learn about your condition and treatments by asking your doctor, the nurse and by using other reliable sources

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Accreditation/Licensing Compliance

Hanover Hospital operating units are required to be licensed by the Commonwealth of Pennsylvania and achieve Medicare Certification. In addition, we participate in voluntary accreditation opportunities, as we believe that performing to established standards is a core responsibility to delivery of quality service. Our performance against the relevant standards follows.

Joint Commission on Accreditation of Health Care Organizations (JCAHO)

Since 1951, JCAHO has developed state-of-the-art, professionally based standards and evaluated the compliance of health care organizations against these benchmarks. Today the Joint Commission evaluates and accredits nearly 18,000 health care organizations and programs in the United States. JCAHO accreditation is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. These standards set forth performance expectations for activites that affect the safety and quality of patient care. To earn and maintain accreditation, an organization must undergo an on-site survey by a JCAHO survey team at least every three years.

Hanover Hospital was surveyed by the Joint Commission, November 7-10, 2006, and received full accreditation status.

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Hanover Hospital
Hanover HealthCarePLUS Network
300 Highland Avenue
Hanover, Pennsylvania, USA 17331
Telephone 717-637-3711
Toll-Free 800-673-2426
TDD 717-633-2230