The Joint Commission National Quality Improvement Goals

Heart attack, heart failure, pneumonia and pregnancy are the four conditions that most commonly bring patients into a hospital for medical treatment. The Joint Commission has established treatment guidelines that when followed have been shown to help patients recover more quickly with fewer complications or lasting effects.

These guidelines cover:

Cedars-Sinai's performance compared to other medical centers and hospitals around the nation and the state are highlighted below. For more detailed information about specific measures, click on the link. These data reflect care given to patients treated at Cedars-Sinai from April to June 2007.

Heart Attack Care Quality Measures

The following measures are based on evidence that the practices described in the left column lead to better outcomes for patients who come to a hospital after or during a heart attack.

Heart Attack Care Quality Measures Cedars-Sinai (July - Sept 2007) All Hospitals Nationwide*
(Oct 2006 - Sept 2007)
Top 10% Scored Average
Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction Percent of heart attack patients who receive a prescription for an ACE inhibitor or an angiotensin receptor blocker when discharged from the hospital 100% 100% 90%
Advice on quitting smoking Percent of adult heart attack patients who are counseled to quit smoking. 100% 100% 98%
Aspirin on arrival Percent of heart attack patients who receive aspirin within 24 hours of arriving at the hospital 100% 100% 97%
Aspirin prescribed at discharge Percent of heart attack patients who prescribed aspirin when discharged 100% 100% 97%
Beta blocker on arrival Percent of eligible heart attack patients who receive a medicine called a beta-blocker within 24 hours of their arrival at the hospital. 100% 100% 94%
Beta blocker prescribed at discharge Percent of eligible heart attack patients prescribed beta-blockers when discharged 100% 100% 97%
Percutaneous coronary intervention (PCI) therapy Percent of heart attack patients with a blocked artery in the heart that is opened with balloon angioplasty (also known as PCI) within 90 minutes of arriving at the hospital 80% 89% 69%

This data represents all hospitals across the United States that report data to the Joint Commission for the Accreditation of Healthcare Organizations.
** This reflects a full year's data, instead of the single quarter's data shown for other measures in the table above.

Heart Failure Care Quality Measures

The following measures are based on evidence that the practices described in the left column lead to better outcomes for patients who come to a hospital with heart failure.

Heart Failure Care Quality Measures Cedars-Sinai (July - Sept 2007) All Hospitals Nationwide*
(Oct 2006 - Sept 2007)
Top 10% Scored Average
Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction Percent of heart attack patients who receive a prescription for an ACE inhibitor or an angiotensin receptor blocker when discharged from the hospital 100% 100% 89%
Advice on quitting smoking Percent of adult heart failure patients who are counseled to quit smoking while in the hospital. 100% 100% 95%
Discharge instructions Percent of heart failure patients who given instructions about managing their diet, weight and medications after leaving the hospital 82% 97% 76%
Left ventricular function assessment Percent of heart failure patients who have had the function of the left ventricle (the main pumping chamber of the heart) checked during their hospital stay 100% 100% 95%

* These data represent all hospitals across the United States that report data to the Joint Commission for the Accreditation of Healthcare Organizations.

Pneumonia Care Quality Measures

The following measures are based on evidence that the practices described in the left column lead to better outcomes for patients who come to a hospital with pneumonia.

Pneumonia Care Quality Measures Cedars-Sinai (July - Sept 2007) All Hospitals Nationwide*
(April 2006 - March 2007)
Top 10% Scored Average
Counseling to quit smoking Percent of adult pneumonia patients who are counseled to stop smoking while in the hospital 100% 100% 93%
Blood cultures Percent of pneumonia patients who are given a blood test before antibiotics are given in the Emergency Department (on arrival) 97% 97% 91%
Blood cultures Percent of pneumonia patients who are given a blood test before antibiotics are given within 24 hours their arrival in the Intensive Care Unit 100% 100% 93%
Antibiotic first received within 4 hours of arrival Percent of pneumonia patients receiving an antibiotic within four hours of arriving at the hospital 93% 93% 82%
Antibiotic first received within 6 hours of arrival Percent of pneumonia patients receiving an antibiotic within six hours of arriving at the hospital 100% 100% 93%
Initial antibiotic selection for community-acquired pneumonia (CAP) in ICU patients Percent of intensive care patients with uncompromised immune systems who have community-acquired pneumonia and received the appropriate antibiotic within 24 hours of arriving at the hospital 50% 100% 66%
Initial antibiotic selection for CAP in non-ICU patients Percent of patients with uncompromised immune systems not in intensive care units who have community-acquired pneumonia and received the appropriate antibiotic within 24 hours of arriving at the hospital 98% 98% 92%
Oxygenation assessment Percent of patients with pneumonia who had the oxygen in their bloodstream measured 100% 100% 100%
Pneumococcal vaccination* Percent of patients 65 and older who were screened and vaccinated to prevent pneumonia. (Note: this measure is seasonal. It covers December 2006 to February 2007.) 98% 97% 82%
Influenza vaccination Percent of pneumonia patients in the hospital during flu season (December 2006 - February 2007) who were given the influenza vaccination before leaving the Medical Center N/A 97% 79%

* These data represent all hospitals across the United States that report data to the Joint Commission for the Accreditation of Healthcare Organizations.

National Patient Safety Goals

The Joint Commission has identified specific actions that the healthcare organizations it accredits are expected to take to prevent medical errors, miscommunication among caregivers and unsafe situations. A panel of national safety experts has determined that taking these simple, proven steps will reduce devastating medical errors.

To see Cedars-Sinai's performance on the National Patient Safety Goals, click here.

Surgical Infection Prevention Care Quality Measures

Preventing infections following surgery is an important element of quality care for surgery patients. To see how Cedars-Sinai performed in terms of preventing surgical infections, click here.

To learn more about the JCAHO Quality Check reports, click here.

Blood Clot Prevention Measures

Certain types of surgery put patients at a higher risk of developing blood clots. To see how Cedars-Sinai performed in terms of providing patients with appropriate and time treatment to prevent blood clots, click here.