BARTON MEMORIAL HOSPITAL (SOUTH LAKE TAHOE, CA) Detailed Hospital Profile

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

This Hospital:	20.6%
California:	13.1%

Percent of long-stay residents who self-report moderate to severe pain

This Hospital:	23.3%
California:	8.9%

Percent of long-stay residents who lose too much weight

This Hospital:	2.3%
State:	6.3%

Percent of long-stay residents with a urinary tract infection

Here:	4.5%
California:	6.7%

Percent of long-stay residents who have depressive symptoms

This Hospital:	2.3%
California:	2.4%

Percent of long-stay residents who were physically restrained

This Hospital:	4.5%
State:	3.6%

Percent of long-stay residents experiencing one or more falls with major injury

This Hospital:	4.5%
State:	1.6%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	100.0%
State:	93.0%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	97.7%
State:	94.0%

Percent of long-stay residents who received an antipsychotic medication

Here:	20.9%
California:	19.0%

Process of Care

Heart Attack

Average number of minutes before outpatients with chest pain or possible heart attack got an ECG

Here:	8
State:	9

Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival

This Hospital:	99.0%
State:	97.2%

Heart Failure

Percent of patients who were given an evaluation of Left Ventricular Systolic Dysfunction (LVSD)

Here:	100.0%
State:	98.9%

Percent of Patients Given Discharge Instructions

Here:	88.0%
State:	93.5%

Pneumonia

Percent of Patients Given Initial Antibiotic(s) within 6 Hours After Arrival

This Hospital:	99.0%
California:	96.1%

Percent of Patients Whose Initial ER Blood Culture Was Performed Prior To Administration Of First Dose Of Antibiotics

This Hospital:	97.0%
California:	96.7%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Hospital:	100.0%
California:	98.1%

Percent of Patients Given the Most Appropriate Initial Antibiotic(s)

This Hospital:	98.0%
California:	95.9%

Percent of Patients Assessed and Given Influenza Vaccination

Here:	94.0%
State:	94.3%

Percent of Patients Assessed and Given Pneumococcal Vaccination

Here:	100.0%
California:	95.8%

Surgery

Percent of Surgery Patients given an antibiotic at the right time (within one hour before surgery) to help prevent infection

This Hospital:	93.0%
State:	98.1%

Percent of Surgery Patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)

Here:	98.0%
State:	96.3%

Percent of Surgery Patients who were given the right kind of antibiotic to help prevent infection

Here:	98.0%
State:	98.2%

Percent of Surgery Patients who got treatment at right time (within 24 hours before or after surgery) to help prevent blood clot

Here:	94.0%
California:	96.0%

Percent of Surgery Patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries

Here:	96.0%
State:	96.9%

Percent of Surgery Patients needing hair removed from the surgical area before surgery who had hair removed using a safer method

This Hospital:	100.0%
State:	99.8%

Percent of Surgery Patients whose urinary catheters were removed on the first or second day after surgery

Here:	98.0%
California:	93.9%

Surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on them

This Hospital:	84.0%
State:	96.1%

Outpatients having surgery who got an antibiotic at the right time - within one hour before surgery (higher numbers are better)

This Hospital:	96.0%
State:	95.1%

Outpatients having surgery who got the right kind of antibiotic (higher numbers are better)

Here:	100.0%
State:	95.5%

Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal

Here:	100.0%
California:	99.6%

Outcome of Care

30-Day Mortality Rates from Heart Failure

Here:	10.8%
California:	10.9%

30-Day Mortality Rates from Pneumonia

Here:	10.8%
State:	11.7%

30-Day Readmission Rates from Heart Failure

Here:	23.9%
State:	24.4%

30-Day Readmission Rates from Pneumonia

Here:	17.4%
State:	18.3%

Complaint Deficiency

Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Some
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed hallway dispensers for alcohol-based hand rub
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide housekeeping and maintenance services
- Harm: Potential for minimal harm
- Scope: Some
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Few
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly working sprinkler alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for
- Harm: Potential for minimal harm
- Scope: Some
Keep each resident free from physical restraints, unless needed for medical treatment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Approved construction type or materials
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly maintained smoke detectors
- Harm: Minimal harm or potential for actual harm
- Scope: Few

Inpatient Prospective Payment System (IPPS) - Medicare Provider Charge Data

Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications

Average Covered Charges

Here:	$37,888
California:	$36,899

Average Total Payments

This Hospital:	$8,332
California:	$6,233

Number of discharges: 21

This Hospital:	16.03%
California:	3.09%

Heart Failure and Shock with Complications

Average Covered Charges

Here:	$32,378
State:	$47,292

Average Total Payments

Here:	$10,411
California:	$8,831

Number of discharges: 17

This Hospital:	12.98%
State:	2.91%

Major Joint Replacement or Reattachment of Lower Extremity without Major Complications

Average Covered Charges

This Hospital:	$67,587
California:	$88,239

Average Total Payments

Here:	$22,365
California:	$17,187

Number of discharges: 53

Here:	40.46%
State:	6.26%

Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours with Major Complications

Average Covered Charges

This Hospital:	$62,495
California:	$90,173

Average Total Payments

Here:	$19,493
California:	$16,748

Number of discharges: 19

This Hospital:	14.50%
State:	7.21%

Simple Pneumonia and Pleurisy with Complications

Average Covered Charges

This Hospital:	$31,269
State:	$48,755

Average Total Payments

This Hospital:	$11,470
State:	$8,695

Number of discharges: 21

This Hospital:	16.03%
California:	2.75%

Use of Medical Imaging

Outpatients with low back pain who had an MRI without trying recommended treatments first, such as physical therapy.

Here:	28.100%
California:	33.932%

Outpatients who had a follow-up mammogram or ultrasound within 45 days after a screening mammogram.

This Hospital:	11.300%
State:	8.180%

Outpatient CT scans of the abdomen that were combination (double) scans.

Here:	0.098%
California:	0.170%

Outpatient CT scans of the chest that were combination (double) scans.

Here:	0.011%
California:	0.043%

Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery

Here:	10.300%
State:	5.492%

Outpatients with brain CT scans who got a sinus CT scan at the same time

This Hospital:	0.900%
California:	1.898%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: 300 or more
Survey Response Rate: 33%

How often did nurses communicate well with patients?

Sometimes or never

This Hospital:	5%
California:	7%

Usually

This Hospital:	17%
State:	21%

Always

This Hospital:	78%
State:	72%

How often did doctors communicate well with patients?

Sometimes or never

Here:	4%
California:	6%

Usually

This Hospital:	17%
State:	17%

Always

Here:	79%
California:	77%

How often did patients receive help quickly from hospital staff?

Sometimes or never

This Hospital:	7%
State:	13%

Usually

Here:	24%
State:	28%

Always

Here:	69%
California:	59%

How often was patients' pain well controlled?

Sometimes or never

Here:	7%
State:	8%

Usually

This Hospital:	23%
California:	25%

Always

Here:	70%
State:	67%

How often did staff explain about medicines before giving them to patients?

Sometimes or never

Here:	19%
State:	23%

Usually

This Hospital:	17%
California:	19%

Always

This Hospital:	64%
State:	58%

How often were the patients' rooms and bathrooms kept clean?

Sometimes or never

This Hospital:	9%
California:	10%

Usually

Here:	16%
State:	21%

Always

Here:	75%
California:	69%

How often was the area around patients' rooms kept quiet at night?

Sometimes or never

Here:	10%
California:	18%

Usually

This Hospital:	35%
State:	33%

Always

Here:	55%
California:	49%

Were patients given information about what to do during their recovery at home?

Yes

This Hospital:	86%
California:	81%

This Hospital:	14%
State:	19%

How do patients rate the hospital overall on a scale from 0 (lowest) to 10 (highest)?

6 or lower

Here:	10%
State:	10%

7 or 8

This Hospital:	23%
California:	24%

9 or 10

Here:	67%
California:	66%

Would patients recommend the hospital to friends and family?

This Hospital:	5%
California:	7%

Yes, probably

This Hospital:	25%
State:	24%

Yes, definitely

This Hospital:	70%
State:	69%

Hospital Acquired Conditions

Falls and injuries

Here:	2.439%
State:	0.625%

Blood infection from a catheter in a large vein

Here:	1.626%
California:	0.530%

Infection from a Urinary Catheter

Here:	0.813%
State:	0.608%

BARTON MEMORIAL HOSPITAL - SOUTH LAKE TAHOE, CA

Quality Measures

Process of Care

Heart Attack

Heart Failure

Pneumonia

Surgery

Outcome of Care

Complaint Deficiency

Inpatient Prospective Payment System (IPPS) - Medicare Provider Charge Data

Use of Medical Imaging

Hospital Consumer Assessment of Healthcare Providers

Hospital Acquired Conditions

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