quality report -...

Quality Report

Alexian Brothers Medical Center

DBA: Alexian Brothers Medical CenterHCO ID: 7340800 Biesterfield RoadElk Grove Village, IL, 60007-3397(847) 437-5500w w w.alexianbrothershealth.org/services/abmc/index.aspx

Summary of Quality Information

Accreditation Programs

View Accreditation History

Home Care AccreditationDecisionAccredited

EffectiveDate6/11/2016

Last Full SurveyDate6/10/2016

Last On-SiteSurvey Date6/10/2016

Hospital AccreditationDecisionAccredited




Advanced Certification Programs

View Certification History

AdvancedComprehensiveStroke Center

CertificationDecisionCertification




© 2016 The Joint Commission, All Rights Reserved.

Core Certification Programs

StrokeRehabilitation

CertificationDecisionCertification




Sites

Addison Care CenterDBA: Alexian Brothers MedicalCenter - Addison Care Center1339 W. Lake St.Addison, IL, 60101

Available Services

Urgent Care (Outpatient )

Alexian Brothers DiagnosticImaging CenterDBA: Alexian Brothers DiagnosticImaging Center1754 W. Golf RoadMount Prospect, IL, 60056

Available Services

Outpatient Clinics (Outpatient )

Alexian Brothers Home HealthDBA: Alexian Brothers Home Health1515 Lake Street, Suite 210Hanover Park, IL, 60133

Available Services

Home Health AidesHome Health, Non-Hospice ServicesMedical Social ServicesOccupational TherapyPhysical TherapySkilled Nursing ServicesSpeech Language Pathology

Alexian Brothers HospiceDBA: Alexian Brothers Hospice1515 E. Lake Street, Suite 206Hanover Park, IL, 60133

Available Services

Hospice Care

Alexian Brothers HospiceResidence

Available Services


DBA: Alexian Brothers HospiceResidence901 Martha StreetElk Grove Village, IL, 60007

Hospice Care

Alexian Brothers MedicalCenterDBA: Alexian Brothers MedicalCenter800 Biesterfield RoadElk Grove Village, IL, 60007-3397

Available Services

Behavioral Health (24-hour AcuteCare/Crisis Stabilization - Adult )Brachytherapy (Imaging/DiagnosticServices )Cardiac Catheterization Lab(Surgical Services )Cardiac Surgery (Surgical Services)Cardiothoracic Surgery (SurgicalServices )Cardiovascular Unit (Inpatient )Coronary Care Unit (Inpatient )CT Scanner (Imaging/DiagnosticServices )Dialysis Unit (Inpatient )Ear/Nose/Throat Surgery (SurgicalServices )EEG/EKG/EMG Lab(Imaging/Diagnostic Services )Gastroenterology (Surgical Services)GI or Endoscopy Lab(Imaging/Diagnostic Services )Gynecological Surgery (SurgicalServices )Gynecology (Inpatient )Hematology/Oncology Unit (Inpatient)Inpatient Unit (Inpatient )Interventional Radiology(Imaging/Diagnostic Services )Labor & Delivery (Inpatient )Magnetic Resonance Imaging(Imaging/Diagnostic Services )Medical /Surgical Unit (Inpatient )Medical ICU (Intensive Care Unit )Neuro/Spine Unit (Inpatient )Neurosurgery (Surgical Services )Normal Newborn Nursery (Inpatient

Other Clinics/Practices Locatedat This Site:

Cardiovascular Imaging Center


)Nuclear Medicine(Imaging/Diagnostic Services )Ophthalmology (Surgical Services )Orthopedic Surgery (SurgicalServices )Orthopedic/Spine Unit (Inpatient )Outpatient Clinics (Outpatient )Pediatric Unit (Inpatient )Positron Emission Tomography (PET)(Imaging/Diagnostic Services )Post Anesthesia Care Unit (PACU)(Inpatient )Radiation Oncology(Imaging/Diagnostic Services )Sleep Laboratory (Sleep Laboratory)Surgical ICU (Intensive Care Unit )Surgical Unit (Inpatient )Teleradiology (Imaging/DiagnosticServices )Thoracic Surgery (Surgical Services)Ultrasound (Imaging/DiagnosticServices )Urology (Surgical Services )Vascular Surgery (SurgicalServices )

Certification Programs

Advanced Comprehensive StrokeCenter

Alexian Brothers NiehoffBuildingDBA: Alexian Brothers MedicalCenter - at Niehoff Building955 S. Beisner RoadElk Grove Village, IL, 60007

Available Services

Outpatient Clinics (Outpatient )Perform Invasive Procedure(Outpatient )

Other Clinics/Practices Locatedat This Site:

Alexian Brothers AnticoagulationClinicAlexian Brothers Sleep HealthCenterAlexian Brothers Wound HealingCenter

Alexian Brothers Wound Available Services


Healing Center - SatelliteDBA: Alexian Brothers MedicalCenter- Wound Healing - Satellite1786 Moon Lake Blvd.Hoffman Estates, IL, 60169

Outpatient Clinics (Outpatient )Perform Invasive Procedure(Outpatient )

Alexian Rehabilitation HospitalDBA: Alexian Brothers -Rehabilitation Hospital935 South Beisner RoadElk Grove Village, IL, 60007

Available Services

Dialysis Unit (Inpatient )Inpatient Unit (Inpatient )Outpatient Clinics (Outpatient )Rehabilitation Unit (Inpatient )Rehabilitation Unit (24-hour AcuteCare/Crisis Stabilization )

Certification Programs

Stroke Rehabilitation

Cardiovascular Imaging CenterDBA: Alexian Brothers MedicalCenter - Cardiovascular Imaging Ctr1555 Barrington Road, DOB III, Suite425Hoffman Estates, IL, 60169

Available Services

Outpatient Clinics (Outpatient )

Special Quality Awards

Due to our commitment to accurate data reporting, The Joint Commission is suspending the practice ofupdating Special Quality Awards until further notice

2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program2012 Silver - The Medal of Honor for Organ Donation

Cooperative Agreements

Hospital - Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)


Symbol Key

This organization achieved the best possible results

This organization's performance is above the target range/value

This organization's performance is similar to the target range/value

This organization's performance is below the target range/value

This measure is not applicable for this organization

Not displayed

Measures Footnote Key

The measure or measure set was not reported.1.

The measure set does not have an overall result.2.

The number is not enough for comparison purposes.3.

The measure meets the Privacy Disclosure Threshold rule.4.

The organization scored above 90% but was below most other organizations.5.

The measure results are not statistically valid.6.

The measure results are based on a sample of patients.7.

The number of months with measure data is below the reporting requirement.8.

The measure results are temporarily suppressed pending resubmission of updated data.9.

Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National

Quality Forum Endorsement.

10.

There were no eligible patients that met the denominator criteria.11.

The Joint Commission only reports measures endorsed by the National Quality Forum.

* This information can also be viewed at Hospital Compare.

** Indicates per 1000 hours of patient care.

*** The measure was not in effect for this quarter.

---- Null value or data not displayed.

National Patient Safety Goals and National Quality Improvement Goals Show Keys +


New Changes to Quarterly Measure

Download Quarterly Measure Results

The Joint Commission only reports measures endorsed by the National Quality Forum.* State results are not calculated for the National Patient Safety Goals.

Hospital 2016 National PatientSafety Goals

NationwideComparison:

StatewideComparison:

Home Care 2016 National PatientSafety Goals

NationwideComparison:

StatewideComparison:

Reporting Period: July 2015 - June 2016

National Quality Improvement Goals:

Emergency Department National Comparison:2

StatewideComparison: 2

Immunization National Comparison:2


Perinatal Care National Comparison:2


Stroke Care National Comparison:2


VenousThromboembolism (VTE)

National Comparison:2


National Quality Improvement Goals:

Alexian Brothers Medical CenterHCO ID: 7340800 Biesterfield RoadElk Grove Village , IL, 60007-3397


Measure Area Nationwide Statewide

Stroke CareRead More

Compared to Other Joint CommissionAccredited Organizations

2 2

Nationwide Statewide

MeasureHospitalResults

Top 10%Scored at Least

AverageRate


AverageRate

Thrombolytic TherapyRead MoreSee Quarterly Results

97% of 32Eligible Patients

100% 89% 100% 89%

Quarterly Measure Results

Jul - Sep 2015

32

90%

87%

Oct - Dec 2015

32

100%

89%

Jan - Mar 2016

32

100%

89%

Apr - Jun 2016

32

100%

90%


VenousThromboembolism(VTE)Read More


2 2

Number of Eligible Patients

Rate

Nationwide Average





AverageRate


AverageRate

VTE Discharge InstructionsRead MoreSee Quarterly Results


100% 93% 100% 87%


Jul - Sep 2015

73

100%

93%

Oct - Dec 2015

73

100%

93%

Jan - Mar 2016

73

100%

93%

Apr - Jun 2016

73

100%

93%


Perinatal CareRead More


2 2


Rate

Nationwide Average





AverageRate


AverageRate

Elective DeliveryRead MoreSee Quarterly Results


0% 2% 0% 1%


Jul - Sep 2015

58

0%

2%

Oct - Dec 2015

58

0%

2%

Jan - Mar 2016

58

9%

2%

Apr - Jun 2016

58

0%

2%




AverageRate


AverageRate

Exclusive Breast Milk FeedingRead MoreSee Quarterly Results


75% 53% 67% 50%


Rate

Nationwide Average



Jul - Sep 2015

379

32%

52%

Oct - Dec 2015

379

40%

52%

Jan - Mar 2016

379

47%

53%

Apr - Jun 2016

379

51%

55%




AverageRate


AverageRate

Antenatal SteroidsRead MoreSee Quarterly Results

3


100% 98% 100% 98%


Jul - Sep 2015

____4

____4

97%

Oct - Dec 2015

____4

____4

98%

Jan - Mar 2016

____4

____4

98%

Apr - Jun 2016

____4

____4

98%


Rate

Nationwide Average


Rate

Nationwide Average



EmergencyDepartmentRead More


2 2



Top 10%Scored at

Most

WeightedMedian

Top 10%Scored at

Most

WeightedMedian

Median Time from ED Arrival to EDDeparture for Admitted ED PatientsRead MoreSee Quarterly Results

2

260 minutes748 eligible

Patients

202 309 210 275


Jul - Sep 2015

748

237

302

Oct - Dec 2015

748

258

301

Jan - Mar 2016

748

286

323

Apr - Jun 2016

748

256

309


Weighted Median Minutes

Nationwide Weighted Median Minutes




Top 10%Scored at

Most

WeightedMedian

Top 10%Scored at

Most

WeightedMedian

Admit Decision Time to ED DepartureTime for Admitted PatientsRead MoreSee Quarterly Results

2

107 minutes748 eligible

Patients

52 122 56 105


Jul - Sep 2015

748

97

116

Oct - Dec 2015

748

83

118

Jan - Mar 2016

748

127

132

Apr - Jun 2016

748

122

123


ImmunizationRead More


2 2


Weighted Median Minutes

Nationwide Weighted Median Minutes





AverageRate


AverageRate

Influenza ImmunizationRead MoreSee Quarterly Results


100% 94% 100% 93%


Jul - Sep 2015

____1

____1

____1

Oct - Dec 2015

637

98%

93%

Jan - Mar 2016

637

100%

95%

Apr - Jun 2016

____1

____1

____1


Rate

Nationwide Average


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