Quality Transparency Dashboard - San Joaquin General Hospital

Introduction

At San Joaquin General Hospital, our mission is to provide high-quality compassionate health care for all who seek it. We’re participating in the Hospital Quality Transparency Dashboard project to enable consumers to make informed choices about their health care through publicly available data about our hospital. Below are our Fiscal Year 2024 results for several key outcome measures. Remember, lower numbers indicate better patient care for these specific measures.

Outcome Measures


Measure (Lower is Better)	CLABSI	Colon SSI	NTSV	Sepsis Mortality	30-Day Readmission
San Joaquin General Hospital	0.492	0.413	25.2	8.1	6.97
Measure Period	7/1/2023 - 6/30/2024
California State Level	0.80	0.89	23.40	15.61	14.75
Measure Period	4/1/2022 – 3/31/2023		7/1/2023 - 6/30/2024	1/1/2022 – 12/31/2022	7/1/2021 – 6/30/2022
National Level	1.0	1.0	26.30	15.00	14.6
Measure Period	1/2023 – 12/2023		1/2023 – 12/2023	1/1/2022 – 12/31/2022	7/1/2021 – 6/30/2022

Measure	SJGH	California State Level	National Level
CLABSI	0.492	0.80	1.0
Colon SSI	0.413	0.89	1.0
NTSV	25.2	23.40	26.30
Sepsis Mortality	8.1	15.61	15.0
30-Day Readmission	6.97	14.75	14.6

Program Status

Maternity Safety Program: Yes	Maternity Safety Program (Program Status Measure)This hospital has a Maternity Safety Program in place. A maternity safety program provides a coordinated approach and emergency response to risks associated with pregnancy and childbirth.
Sepsis Protocol: Yes	Sepsis Protocol (Program Status Measure) This hospital has a Sepsis Protocol in place. A sepsis protocol provides guidance for a coordinated approach to identification and treatment of an infection and inflammatory response which is present throughout the body.
Respiratory Monitoring Program: Yes	Respiratory Monitoring Program (Program Status Measure) This hospital has a Respiratory Monitoring program in place. Respiratory monitoring provides guidance for assessment of risk of respiratory depression, and includes continuous monitoring of breathing and functioning of the lungs and circulatory system when indicated.

Outcome Measure Definitions

	CLABSI – CENTRAL LINE-ASSOCIATED BLOOD STREAM INFECTION A central line-associated blood stream infection is a serious infection that occurs when bacteria or germs enter the bloodstream through an IV called a central line. A central line allows access to a major vein close to the heart and can stay in place for weeks or months. It is mainly used for medication delivery and blood draws. Central line infections are measured using the Centers for Disease Control and Prevention Standardized Infection Ratio (SIR). This ratio is the observed number of infections divided by the number of expected infections. Values less than 1.00 show that the number of observed infections was lower than expected.Values more than 1.00 show that the number of infections was higher than expected. N/A means the scoring related to predicted infections is not available.
	COLON SSI – SURGICAL SITE INFECTION FROM COLON SURGERY A surgical site infection occurs after surgery and is caused by bacteria or germs in the part of the body where the surgery took place. Surgical site infections for colon surgery are measured using the Centers for Disease Control and Prevention Standardized Infection Ratio (SIR). This ratio is the observed number of infections divided by the number of expected infections. Values less than 1.00 show that the number of observed infections was lower than expected. Values more than 1.00 show that the number of infections was higher than expected. N/A means the scoring related to predicted infections is not available.
	NTSV – NULLIPAROUS, TERM, SINGLETON, VERTEX CESAREAN BIRTH RATE The percentage of cesarean (surgical) births among first -time mothers who are at least 37 weeks pregnant with one baby in a head down position (not breech or transverse). Lower values indicate that fewer cesareans were performed in the hospital among primarily low risk, first -time mothers.
	SEPSIS MORTALITY Sepsis or septic shock is the body’s extreme response to an infection. It is a life-threatening medical emergency that is a risk for patients admitted to an emergency department or hospital care setting. Without timely treatment, sepsis can lead to tissue damage, organ failure (e.g., kidney, lungs, liver, etc.), and death. Sepsis infection is measured by the percent of patients who die in the hospital. A lower number shows a better outcome.
	30-DAY READMISSION – HOSPITAL-WIDE ALL-CAUSE 30-DAY UNPLANNED READMISSION RATE The percentage of patients who were unexpectedly readmitted within 30 days of discharge from the hospital for any reason. Lower values indicate that fewer cases were unexpectedly readmitted after discharge.

National Initiatives

Efforts to improve outcomes include adopting evidence-based guidelines, multidisciplinary teams, patient education, and regular audits.

	CLABSI – prevention efforts include but are not limited to: Adopt vascular access policies that highlight appropriate device selection criteria and maintenance criteria Implement daily justification of central lines by providers Provide daily chlorhexidine bathing in critical care to reduce bioburden Eliminate unnecessary vascular access devices to limit portals of entry Utilization of checklist for inserting, managing and device needs
	COLON SSI – prevention efforts include but are not limited to : Adopt an evidenced based colorectal bundle that focuses on prevention efforts before, during, and after the surgical procedure Perform Audits of instrument handling from point of use to storage, utilizing an evidenced based sterilization audit checklist Perform active surveillance to identify commonalities and trends with associated action plans
	NTSV – prevention efforts include but are not limited to: Provide feedback to physicians by providing Cesarean Birth data reports Create a multidisciplinary perinatal quality and safety improvement team to create action plans Educate physicians, clinical staff, patients and their families on the risk and benefits on cesarean birth Provide recommendations to physicians and clinical staff on labor management of low risk women
	SEPSIS MORTALITY – prevention efforts include but are not limited to : Adopt vascular access policies that highlight appropriate device selection criteria and maintenance criteria Implement daily justification of central lines by providers Provide daily chlorhexidine bathing in critical care to reduce bioburden Eliminate unnecessary vascular access devices to limit portals of entry Utilization of checklist for inserting, managing and device needs
	CLABSI – prevention efforts include but are not limited to: Adopt the evidence based sepsis guidelines that focus on the management of the severe sepsis and septic shock patient Review mortality cases for opportunities, develop action plans and discuss within the facilities multidisciplinary team Monitor for SEP-1 bundle compliance and opportunities for improvement Adopt tracking and hand off process to ensure bundle compliance is completed Provide patient/family education on sepsis
	30-DAY READMISSION – prevention efforts include but are not limited to: Adopt evidence based practices to reduce readmissions Convene a multidisciplinary readmission improvement team focused on developing improvement strategies and utilizing data to drive initiatives Refer patients to the most appropriate post -acute setting Identification of patients at high risk for readmissions and align the intensity of discharge planning to their readmission risk Begin discharge planning upon admission Provide individualized patient discharge education Medication reconciliation prior to discharge with “Med to Bed” programs Prior to discharge, schedule the patient’s post -discharge visit with their primary care provider Discharge phone calls

San Joaquin General Hospital

has the following in place:

Maternity Safety Program
Sepsis Protocol
Respiratory Monitoring Program