GeorgiaHospital Quality Measures Compared to Achievable Benchmarks

The NHQDR quality measures specific to Hospital are compared to achievable benchmarks, which are derived from the top-performing States. Better performance of a State can mean higher or lower values of a measure, depending on the desired outcome. For example, low values are desirable for measures such as infant mortality, whereas high values are desirable for measures such as preventative screening. The categories of achievement have been standardized across the measure definitions so that:

 
Far away from benchmark - a State's value for a measure has not achieved 50% of the benchmark.
 
Close to benchmark - a State's value for a measure is between 50% and 90% of a benchmark (i.e., worse than the benchmark but has achieved at least half of the benchmark but not as much as 90% of a benchmark).
 
Achieved benchmark or better - a State's value for a measure is no worse than 90% of the benchmark value, the measure has achieved the benchmark. This category also includes the case in which the measure’s value is equal to or better than the benchmark.
Measures That Achieved Benchmark or Better
Measure Estimate Benchmark Distance to Benchmark
Stroke patients who received venous thromboembolism (VTE) prophylaxis 98.0 98.7 0.7%
Stroke patients prescribed statin medication at hospital discharge 97.5 98.6 1.1%
Stroke patients with educational material addressing activation of emergency medical system, follow-up after discharge, educations prescribed at discharge, risk factors for stroke, warning signs and symptoms of stroke 94.9 96.7 1.9%
Women with clinical Stage I-IIb breast cancer who received axillary node dissection or sentinel lymph node biopsy (SLNB) at the time of surgery (lumpectomy or mastectomy) 94.5 96.8 2.4%
Patients with colon cancer who received surgical resection of colon cancer that included at least 12 lymph nodes pathologically examined 92.3 95.3 3.1%
Women under age 70 treated for breast cancer with breast-conserving surgery who received radiation therapy to the breast within 1 year of diagnosis 93.7 97.0 3.4%
Hospital patients who received influenza vaccination 92.8 97.0 4.3%
Measures That Are Close to Benchmark
Measure Estimate Benchmark Distance to Benchmark
Acute stroke patients for whom IV thrombolytic therapy was initiated at hospital within 3 hours of time last known well 83.0 92.9 10.7%
Home health care patients whose surgical wound was improved 90.7 80.3 12.9%
Hospital inpatient stays involving opioid-related diagnoses per 100,000 population 118.3 102.9 15.0%
Adult hospital patients who sometimes or never had good communication about medications they received in the hospital 10.5 7.8 35.3%
Measures That Are Far From Benchmark
Measure Estimate Benchmark Distance to Benchmark
Adult hospital patients who did not receive good communication about discharge information 12.2 7.7 58.0%
Home health care patients who had an emergency department visit and then hospitalized 21.7 13.5 60.3%
Emergency department visits involving opioid-related diagnoses per 100,000 population 119.4 65.2 83.0%
Adult hospital patients who strongly disagree or disagree that staff took their preferences and those of their family and caregiver into account when deciding what the patients discharge health care would be 6.4 3.2 97.5%
Measures With No Available Benchmark Information or Supplemental Measures
Measure Estimate Benchmark Distance to Benchmark
Median time in minutes patients who came to the emergency department with broken bones had to wait before getting pain medication 55.0
Median time in minutes patients with psychiatric or mental health conditions spent at emergency department (ED) from ED arrival to ED departure 270.0
Patients who developed a blood clot while in the hospital who did not get treatment that could have prevented it 1.7
Median time in minutes patients spent in the emergency department before they were seen by a healthcare professional 26.0
Median time in minutes spent in the emergency department (ED) from admission decision to ED departure for admitted patients 102.0
Median time in minutes patients spent at emergency department (ED) from ED arrival to ED departure 140.0
Median time in minutes spent in the emergency department (ED) from ED arrival to ED departure for admitted patients 298.0
Radiation therapy was recommended or administered following any mastectomy within 1 year of diagnosis of breast cancer for women with 4 positive regional lymph nodes 88.7
Outpatients with chest pain or possible heart attack who received fibrinolytic therapy within 30 minutes of arrival 49.1
Median time in minutes outpatients with chest pain or possible heart attack from emergency department arrival to get ECG 8.0
Median time in minutes before outpatients with chest pain or possible heart attack who needed specialized care were transferred to another hospital and did not have contraindication to fibrinolytic 75.0
Combination chemotherapy was recommended or administered within 4 months of diagnosis for women under 70 with AJCC T1cN0MO or Stage IB-III hormone receptor negative breast cancer 94.5
Tamoxifen or third generation aromatase inhibitor was recommended or administered within 1 year of diagnosis for women with AJCC T1cN0M0 or stage IB to stage III hormone receptor-positive breast cancer 85.7
Radiation therapy was completed within 60 days of initiation of radiation among women diagnosed with any stage of cervical cancer 79.2
Use of brachytherapy in patients treated with primary radiation with curative intent in any stage of cervical cancer 70.0
Adjuvant chemotherapy was recommended or administered within 4 months of diagnosis for patients under the age of 80 with AJCC Stage III lymph node positive colon cancer 91.3
Patients who came to the emergency department (ED) with stroke symptoms and received head CT or MRI who received the interpretation of the results within 45 minutes of ED arrival 67.9
Median time in minutes outpatients with chest pain or possible heart attack who got drugs to break up blood clots after arrival 31.0