Quality Report - Americaneagle.compr-pdf-1vwb01.americaneagle.com/qualitycheck/files/28d...2016/08/17 · Quality Report University of North Carolina Hospitals HCO ID: 6478 101 Manning

Quality Report

University of North Carolina HospitalsHCO ID: 6478101 Manning DriveChapel Hill, NC, 27514(984) 974-3041w w w.unchealthcare.org

Summary of Quality Information

Accreditation Programs

View Accreditation History

Behavioral HealthCare

AccreditationDecisionAccredited

EffectiveDate8/17/2016

Last Full SurveyDate8/16/2016

Last On-SiteSurvey Date8/16/2016

Home Care AccreditationDecisionAccredited




Hospital AccreditationDecisionAccredited




© 2016 The Joint Commission, All Rights Reserved.

Advanced Certification Programs

View Certification History

AdvancedComprehensiveStroke Center

CertificationDecisionCertification




Ventricular AssistDevice

CertificationDecisionCertification




Sites

Alcohol & Substance AbuseProgram, UNC Hospitals1101 Weaver Dairy Road, Suite 103Chapel Hill, NC, 27514

Available Services

Chemical Dependency (Non 24 HourCare - Adult )Chemical Dependency (Non 24 HourCare - Child/Youth )Peer Support (Non 24 Hour Care )

Alcohol and DrugDetoxification Unit atWakeBrook, UNC HealtSuite A, 107 Sunnybrook Rd.Raleigh, NC, 27610

Available Services

Behavioral Health (Residential Care -Adult )Case Management (Non 24 HourCare - Adult )Community Integration (Non 24 HourCare )Family Support (Non 24 Hour Care )

Ambulatory Care Clinics, UNCHospitals102 Mason Farm Rd.Chapel Hill, NC, 27599

Available Services

Outpatient Clinics (Outpatient )

Other Clinics/Practices Locatedat This Site:

ACC Orthopaedic Radiology, UNCHospitalsACC Physical Therapy, UNCHospitalsACC Radiology, UNC Hospitals


Hand Rehabilitation Center, UNCHospitalsKidney and HypertensionSpeciality Clinic, UNC HospitalsMcLendon Lab, UNC HospitalsOutpatient Pharmacy, UNCHospitals

Ambulatory Surgical Center,UNC Hospitals102 Mason Farm RoadChapel Hill, NC, 27514

Available Services

Administration of Blood Product(Outpatient )Administration of High RiskMedications (Outpatient )Ambulatory Surgery Center(Outpatient )Anesthesia (Outpatient )Perform Invasive Procedure(Outpatient )

Benign Hematology Clinic ,UNC Hospitals6013 Farrington Road, Suite 201Chapel Hill, NC, 27517

Available Services


Burlington Imaging and BreastCenter, UNC Hospitals1225 Huffman Mill RoadChapel Hill, NC, 27515

Available Services


Burn Reconstruction andAesthetics Center, UNC HealthCareDBA: Burn Reconstruction andAesthetics Center151 Old University Station Rd.Chapel Hill, NC, 27514

Available Services

Anesthesia (Outpatient )Perform Invasive Procedure(Outpatient )Single Specialty Practitioner(Outpatient )

Cardiac Rehabilitation, UNCHospitalsMeadowmont Village, 100 Sprunt

Available Services



StreetChapel Hill, NC, 27517

Carolina Pointe II OrthopaedicRadiology, UNC Hospitals6011 Farrington Rd, Suite 201Chapel Hill, NC, 27517

Available Services

Single Specialty Practitioner(Outpatient )

Carolina Pointe II Radiology,UNC HospitalsCarolina Pointe II, 6013 FarringtonRoad, Ste. 102Chapel Hill, NC, 27517-8822

Available Services


Center for Rehabilitation Care,UNC Hospitals1807 North Fordham Blvd.Chapel Hill, NC, 27516

Available Services


Comprehensive CancerSupport Program, UNCHospitalsDBA: CCSP170 Manning Drive, CB#7305Chapel Hill, NC, 27599-7305

Available Services


Comprehensive CancerSupport Program, UNCHospitalsDBA: CCSP6011 Farrington RoadChapel Hill, NC, 27517

Available Services


Diabetes & Endocinology Clinicat Meadowmont, UNCHospitals300 Meadowmont Village Circle,Suite 202Chapel Hill, NC, 27517

Available Services



Endoscopy Center, UNCHospitals300 Meadowmont Village, Suite 335Chapel Hill, NC, 27517

Available Services

Administration of High RiskMedications (Outpatient )Ambulatory Surgery Center(Outpatient )Anesthesia (Outpatient )Perform Invasive Procedure(Outpatient )

Facility Based Crisis atWakebrook, UNC Health CareSuite B, 107 Sunnybrook Rd.Raleigh, NC, 27609

Available Services

Behavioral Health (Residential Care -Adult )Case Management (Non 24 HourCare - Adult )


UNC Hospital at WakebrookPharmacy

Geriatric Specialty Clinic, UNCHospitalsCarolina Point II, 6011 FarringtonRoad, Suite 101Chapel Hill, NC, 27514

Available Services


GI Medicine Clinic, UNCHospitals5915 Farrington Road, Suite 105Chapel Hill, NC, 27517

Available Services


GI Procedures at Hillsborough,UNC Health Care460 Waterstone DriveHillsborough, NC, 27278

Available Services

Administration of High RiskMedications (Outpatient )Anesthesia (Outpatient )Outpatient Clinics (Outpatient )Perform Invasive Procedure(Outpatient )

Hearing and Voice Center, UNCHospitalsCarolina Crossing, 2226 Nelson

Available Services



Hwy, Suite 100Chapel Hill, NC, 27514

Heart & Vascular Center, UNCHospitals300 Meadowmont Village Circle,Suite 301Chapel Hill, NC, 27517

Available Services

Administration of High RiskMedications (Outpatient )Outpatient Clinics (Outpatient )Perform Invasive Procedure(Outpatient )


Cardiovascular Studies, UNCHospitalsMeadowmont Peripheral VascularLab, UNC HospitalsVascular Interventional Radiology,UNC Hospitals

Home Health, UNC Hospitals1101 Weaver Dairy Road Suite 200Chapel Hill, NC, 27514

Available Services

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

Homecare Specialists, UNCHospitals4400 Emperor Blvd.Durham, NC, 27703

Available Services

Canes and CrutchesClinical RespiratoryCommodesContinuous Passive Motion (CPM)DeviceContinuous Positive AirwayPressureDurable Medical EquipmentEnteral Equipment and/or SuppliesEnteral NutrientsExternal Infusion Pump SuppliesExternal Infusion PumpsGastric Suction PumpsHospital Beds - ElectricHospital Beds - ManualNebulizers EquipmentNegative Pressure WoundOxygen


Pharmacy


Parenteral Equipment and/orSuppliesParenteral NutrientsPatient Lifts and AccessoriesPharmacy/Dispensary,GeneralServicesPower Operated Vehicles (orscooters)Power WheelchairsProsthetics (Home MedicalEquipment)Respiratory Assist DevicesRespiratory EquipmentSeat Lift MechanismsSuction PumpSuppliesSupport Surfaces for Beds (New)Tens UnitsTracheostomy SuppliesUltaviolet Light DevicesWalkers, Canes and CrutchesWheelchair Seating / CushionsWheelchairs - Manual Non-CustomWheelchairs-Standard ManualRelated Accessories and Repairs

Imaging and Spine Center, UNCHospitals1350 Raleigh RoadChapel Hill, NC, 27517

Available Services

Anesthesia (Outpatient )Outpatient Clinics (Outpatient )Perform Invasive Procedure(Outpatient )


Occupational Therapy/PhysicalTherapy, UNC HospitalsSpine Center and NeurosurgeryClinic, UNC Hospitals

McCreary Cancer Center, AService of UNC Hospitals212 Mulberry Street, SWLenoir, NC, 28645

Available Services

Administration of Blood Product(Outpatient )Administration of High RiskMedications (Outpatient )Outpatient Clinics (Outpatient )

N.C. Children's Specialty Clinic, Available Services


UNC Hospitals4414 Lake Boone Trail, Ste 505Raleigh, NC, 27607


Neurology Clinic, UNCHospitals194 Finley Golf Course RdChapel Hill, NC, 27517

Available Services


Occupational Therapy/PhysicalTherapy Clinic, UNC HospitalsDBA: OccupationalTherapy/Physical Therapy ClinicCarolina Pointe II, 6013 FarringtonRoad, Ste.301, Bldg.200Chapel Hill, NC, 27517

Available Services


Oncology Services, UNCHospitalsHillsborough Campus, 460Waterstone DriveHillsborough, NC, 27278

Available Services

Administration of High RiskMedications (Outpatient )Single Specialty Practitioner(Outpatient )

Pain Management Clinic, UNCHospitalsSouthern Village- 410 Market St,Suite 362.Chapel Hill, NC, 27516

Available Services


Pittsboro Business Center -Hospice, UNC HospitalsDBA: UNC Hospice480 Hillsboro Street, Suite 800Pittsboro, NC, 27312

Rheumatology Specialty Clinic,UNC Hospitals6013 Farrington Road, Building 200,Suite 301

Available Services

Administration of High RiskMedications (Outpatient )


Chapel Hill, NC, 27514 Outpatient Clinics (Outpatient )

Therapeutic Infusion Center,UNC Hospitals6013 Farrington Rd., Suite 201Chapel Hill, NC, 27517

Available Services


UNC Hospitals at Wakebrook111 Sunnybrook Rd.Raleigh, NC, 27609

Available Services

Behavioral Health (24-hour AcuteCare/Crisis Stabilization - Adult )Community Integration (Non 24 HourCare )Family Support (Non 24 Hour Care )


UNC Health Care at Wake BrookPharmacy

UNC Hospitals Family MedicineRadiologyDBA: Family Medicine Radiology590 Manning Drive, Room 184Chapel Hill, NC, 27599

Available Services



UNC Hospitals Family MedicineCenter Laboratory

UNC Hospitals HillsboroughCampus430 Waterstone DriveHillsborough, NC, 27278

Available Services

CT Scanner (Imaging/DiagnosticServices )EEG/EKG/EMG Lab(Imaging/Diagnostic Services )Gastroenterology (Surgical Services)Gynecological Surgery (SurgicalServices )Inpatient Unit (Inpatient )Magnetic Resonance Imaging(Imaging/Diagnostic Services )Medical /Surgical Unit (Inpatient )Medical ICU (Intensive Care Unit )Neurosurgery (Surgical Services )Nuclear Medicine(Imaging/Diagnostic Services )Ophthalmology (Surgical Services )Orthopedic Surgery (Surgical


Services )Outpatient Clinics (Outpatient )Surgical ICU (Intensive Care Unit )Ultrasound (Imaging/DiagnosticServices )Urology (Surgical Services )

UNC Hospitals Laboratory,Carolina Pointe IICarolina Point II, 6013 FarringtonRoad, Suite 101Chapel Hill, NC, 27517

Available Services


UNC Hospitals Nutrition Clinic590 Manning DriveChapel Hill, NC, 27599

Available Services


University of North CarolinaHospitals101 Manning DriveChapel Hill, NC, 27514

Available Services

Behavioral Health (24-hour AcuteCare/Crisis Stabilization - Adult )Brachytherapy (Imaging/DiagnosticServices )Burn Unit (Inpatient )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 )Eating DisordersEating DisordersEating Disorders (Inpatient - Adult )Eating Disorders (Outpatient -Child/Youth )Eating Disorders (Non 24 Hour Care


- Child/Youth )Eating Disorders (24-hour AcuteCare/Crisis Stabilization - Adult )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 ICU (Intensive Care Unit)Neuro/Spine Unit (Inpatient )Neurosurgery (Surgical Services )Normal Newborn Nursery (Inpatient)Nuclear Medicine(Imaging/Diagnostic Services )Ophthalmology (Surgical Services )Orthopedic Surgery (SurgicalServices )Orthopedic/Spine Unit (Inpatient )Outpatient Clinics (Outpatient )Pediatric Unit (Inpatient )Plastic Surgery (Surgical Services )Positron Emission Tomography (PET)(Imaging/Diagnostic Services )Post Anesthesia Care Unit (PACU)(Inpatient )Radiation Oncology(Imaging/Diagnostic Services )Rehabilitation Unit (Inpatient )Rehabilitation Unit (24-hour AcuteCare/Crisis Stabilization )Sleep Laboratory (Sleep Laboratory


)Surgical ICU (Intensive Care Unit )Surgical Unit (Inpatient )Teleradiology (Imaging/DiagnosticServices )Thoracic Surgery (Surgical Services)Transplant Surgery (SurgicalServices )Ultrasound (Imaging/DiagnosticServices )Urology (Surgical Services )Vascular Surgery (SurgicalServices )

Certification Programs

Advanced Comprehensive StrokeCenterVentricular Assist Device

Urology Services, UNCHospitalsDBA: Urology Services, UNCHospitalsCarolina Point 1, 5915 FarringtonRd., Suite 102Durham, NC, 27705

Available Services


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 Program2014 Gold Plus Get With The Guidelines - Stroke


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:

Behavioral HealthCare

2016 National PatientSafety Goals



Home Care 2016 National PatientSafety Goals



Reporting Period: July 2015 - June 2016

National Quality Improvement Goals:

Emergency Department National Comparison:2

StatewideComparison: 2

Hospital-Based InpatientPsychiatric Services

National Comparison:2


Immunization National Comparison:2


Perinatal Care National Comparison:2


Stroke Care National Comparison:2


VenousThromboembolism (VTE)

National Comparison:2



National Quality Improvement Goals:

University of North Carolina HospitalsHCO ID: 6478101 Manning DriveChapel Hill , NC, 27514

Measure Area Nationwide Statewide

Hospital-BasedInpatientPsychiatricServicesRead More

Compared to Other Joint CommissionAccredited Organizations

2 2

Nationwide Statewide

MeasureHospitalResults

Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Assessment of violence risk, substance usedisorder, trauma and patient strengthscompleted - Overall RateRead MoreSee Quarterly Results

76% of782

EligiblePatients

100% 94% 100% 95%


Quarterly Measure Results

Jul - Sep 2015

782

58%

94%

Oct - Dec 2015

782

83%

94%

Jan - Mar 2016

782

87%

94%

Apr - Jun 2016

782

76%

94%



Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Assessment of violence risk, substance usedisorder, trauma and patient strengthscompleted - Children (1-12 years)Read MoreSee Quarterly Results

47% of141

EligiblePatients

100% 96% 100% 84%


Jul - Sep 2015

141

32%

96%

Oct - Dec 2015

141

65%

96%

Jan - Mar 2016

141

52%

95%

Apr - Jun 2016

141

39%

96%

Number of Eligible Patients

Rate

Nationwide Average


Rate

Nationwide Average




Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Assessment of violence risk, substance usedisorder, trauma and patient strengthscompleted - Adolescent (13-17 years)Read MoreSee Quarterly Results

81% of171

EligiblePatients

100% 97% 100% 95%


Jul - Sep 2015

171

63%

97%

Oct - Dec 2015

171

83%

97%

Jan - Mar 2016

171

89%

97%

Apr - Jun 2016

171

88%

97%



Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Assessment of violence risk, substance usedisorder, trauma and patient strengthscompleted - Adult (18-64 years)Read MoreSee Quarterly Results

85% of328

EligiblePatients

100% 94% 100% 96%


Rate

Nationwide Average



Jul - Sep 2015

328

69%

94%

Oct - Dec 2015

328

93%

94%

Jan - Mar 2016

328

96%

93%

Apr - Jun 2016

328

83%

94%



Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Assessment of violence risk, substance usedisorder, trauma and patient strengthscompleted - Older Adult (>= 65 years)Read MoreSee Quarterly Results

76% of142

EligiblePatients

100% 92% 100% 90%


Jul - Sep 2015

142

53%

93%

Oct - Dec 2015

142

77%

92%

Jan - Mar 2016

142

94%

92%

Apr - Jun 2016

142

85%

93%


Rate

Nationwide Average


Rate

Nationwide Average




Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Multiple Antipsychotic Medications atDischarge with Appropriate JustificationOverall RateRead MoreSee Quarterly Results

3

39% of 23EligiblePatients

100% 62% 100% 81%


Jul - Sep 2015

23

33%

63%

Oct - Dec 2015

23

36%

64%

Jan - Mar 2016

23

33%

62%

Apr - Jun 2016

23

67%

60%



Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Multiple Antipsychotic Medications at Dischargewith Appropriate Justification Children Age 1 -12Read More(No Quarterly Result are available)

3

----100% 62% ____3 ____3


Rate

Nationwide Average



Jul - Sep 2015

____1

____1

____1

Oct - Dec 2015

____1

____1

____1

Jan - Mar 2016

____1

____1

____1

Apr - Jun 2016

____1

____1

____1



Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Multiple Antipsychotic Medications at Dischargewith Appropriate Justification Adolescents Age13 - 17Read More(No Quarterly Result are available)

4

----100% 61% ____3 ____3


Jul - Sep 2015

____1

____1

____1

Oct - Dec 2015

____1

____1

____1

Jan - Mar 2016

____1

____1

____1

Apr - Jun 2016

____1

____1

____1


Rate

Nationwide Average


Rate

Nationwide Average




Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Multiple Antipsychotic Medications atDischarge with Appropriate JustificationAdults Age 18 - 64Read MoreSee Quarterly Results

3


100% 63% 100% 82%


Jul - Sep 2015

____4

____4

64%

Oct - Dec 2015

17

17%

65%

Jan - Mar 2016

17

33%

62%

Apr - Jun 2016

17

67%

62%



Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Multiple Antipsychotic Medications atDischarge with Appropriate Justification OlderAdults Age 65 and OlderRead MoreSee Quarterly Results

3


100% 56% 100% 75%


Rate

Nationwide Average



Jul - Sep 2015

____4

____4

57%

Oct - Dec 2015

5

75%

58%

Jan - Mar 2016

____1

____1

58%

Apr - Jun 2016

____1

____1

53%



Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Hours of Physical Restraint Use per1000 Patient Hours - Overall RateRead MoreSee Quarterly Results

0.1056(92 Total Hours in

Restraints)

N/A 0.4876 N/A 0.5467


Jul - Sep 2015

208.0080

14.5333

0.0699

0.5156

Oct - Dec 2015

212.6880

47.3667

0.2227

0.4559

Jan - Mar 2016

211.6800

16.2000

0.0765

0.4618

Apr - Jun 2016

236.6640

13.6833

0.0578

0.5019


Rate

Nationwide Average

Total Patient Hours/1000

Total Patient Hours in Restraint

Rate of Restraint Use**

Nationwide Rate**




Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Hours of Physical Restraint UseChildren Age 1 - 12Read MoreSee Quarterly Results


Restraints)

N/A 0.3128 N/A 0.354


Jul - Sep 2015

15.4320

4.5833

0.2970

0.3423

Oct - Dec 2015

18.8160

2.7667

0.1470

0.3438

Jan - Mar 2016

15.3600

1.9667

0.1280

0.3122

Apr - Jun 2016

15.0000

6.6833

0.4456

0.2632



Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Hours of Physical Restraint UseAdolescents Age 13 - 17Read MoreSee Quarterly Results


Restraints)

N/A 0.3159 N/A 0.175




Nationwide Rate**



Jul - Sep 2015

33.9120

3.0833

0.0909

0.3003

Oct - Dec 2015

33.1440

0.0500

0.0015

0.2326

Jan - Mar 2016

33.4800

11.7167

0.3500

0.2194

Apr - Jun 2016

33.7200

2.4167

0.0717

0.4930



Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Hours of Physical Restraint UseAdults Age 18 - 64Read MoreSee Quarterly Results


Restraints)

N/A 0.5142 N/A 0.1433




Nationwide Rate**



Jul - Sep 2015

134.6160

4.1667

0.0310

0.5219

Oct - Dec 2015

135.3120

4.4167

0.0326

0.5053

Jan - Mar 2016

138.5040

1.5333

0.0111

0.4893

Apr - Jun 2016

168.8640

3.1000

0.0184

0.5258



Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Hours of Physical Restraint UseOlder Adults Age 65 and OlderRead MoreSee Quarterly Results


Restraints)

N/A 0.4777 N/A 4.0872




Nationwide Rate**



Jul - Sep 2015

24.0480

2.7000

0.1123

0.6561

Oct - Dec 2015

25.4160

40.1333

1.5791

0.3105

Jan - Mar 2016

24.3360

0.9833

0.0404

0.5057

Apr - Jun 2016

19.0800

1.4833

0.0777

0.4039



Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Hours of Seclusion Use per 1000Patient Hours - Overall RateRead MoreSee Quarterly Results


Seclusion)

N/A 0.3612 N/A 0.1022




Nationwide Rate**



Jul - Sep 2015

208.0080

71.2833

0.3427

0.3642

Oct - Dec 2015

212.6880

44.6333

0.2099

0.3719

Jan - Mar 2016

211.6800

31.3833

0.1483

0.3574

Apr - Jun 2016

236.6640

134.5167

0.5684

0.3446



Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Hours of Seclusion UseChildren Age 1 - 12Read MoreSee Quarterly Results


Seclusion)

N/A 0.5425 N/A 0.353


Total Patient Hours in Seclusion

Rate of Seclusion Use**

Nationwide Rate**



Jul - Sep 2015

15.4320

11.1333

0.7214

0.5224

Oct - Dec 2015

18.8160

15.6500

0.8317

0.6198

Jan - Mar 2016

15.3600

8.4833

0.5523

0.5541

Apr - Jun 2016

15.0000

15.4833

1.0322

0.4847



Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Hours of Seclusion UseAdolescents Age 13 - 17Read MoreSee Quarterly Results


Seclusion)

N/A 0.2001 N/A 0.1279




Nationwide Rate**



Jul - Sep 2015

33.9120

24.2333

0.7146

0.2564

Oct - Dec 2015

33.1440

5.7500

0.1735

0.1732

Jan - Mar 2016

33.4800

7.5833

0.2265

0.1957

Apr - Jun 2016

33.7200

5.9333

0.1760

0.1852



Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Hours of Seclusion Use AdultsAge 18 - 64Read MoreSee Quarterly Results


Seclusion)

N/A 0.4089 N/A 0.0966




Nationwide Rate**



Jul - Sep 2015

134.6160

17.6167

0.1309

0.4063

Oct - Dec 2015

135.3120

22.3500

0.1652

0.4171

Jan - Mar 2016

138.5040

12.5833

0.0909

0.4088

Apr - Jun 2016

168.8640

113.1000

0.6698

0.3962



Top 10%Scored at

Least

AverageRate

Top 10%Scored at

Least

AverageRate

Hours of Seclusion Use OlderAdults Age 65 and OlderRead MoreSee Quarterly Results


Seclusion)

N/A 0.0918 N/A 0.0382




Nationwide Rate**



Jul - Sep 2015

24.0480

18.3000

0.7610

0.0934

Oct - Dec 2015

25.4160

0.8833

0.0348

0.1371

Jan - Mar 2016

24.3360

2.7333

0.1123

0.0660

Apr - Jun 2016

19.0800

0

0

0.0684


Stroke CareRead More


2 2



Top 10%Scored at Least

AverageRate


AverageRate

Thrombolytic TherapyRead MoreSee Quarterly Results

100% of 11Eligible Patients

100% 89% 100% 91%




Nationwide Rate**



Jul - Sep 2015

____1

____1

87%

Oct - Dec 2015

____4

____4

89%

Jan - Mar 2016

11

100%

89%

Apr - Jun 2016

11

100%

90%


VenousThromboembolism(VTE)Read More


2 2




AverageRate


AverageRate

VTE Discharge InstructionsRead MoreSee Quarterly Results


100% 93% 100% 95%


Rate

Nationwide Average



Jul - Sep 2015

62

100%

93%

Oct - Dec 2015

62

100%

93%

Jan - Mar 2016

62

100%

93%

Apr - Jun 2016

62

100%

93%


Perinatal CareRead More


2 2




AverageRate


AverageRate

Elective DeliveryRead MoreSee Quarterly Results


0% 2% 0% 1%


Rate

Nationwide Average



Jul - Sep 2015

46

0%

2%

Oct - Dec 2015

46

0%

2%

Jan - Mar 2016

46

0%

2%

Apr - Jun 2016

46

0%

2%




AverageRate


AverageRate

Exclusive Breast Milk FeedingRead MoreSee Quarterly Results


75% 53% 66% 47%


Jul - Sep 2015

399

75%

52%

Oct - Dec 2015

399

55%

52%

Jan - Mar 2016

399

66%

53%

Apr - Jun 2016

399

69%

55%


Rate

Nationwide Average


Rate

Nationwide Average





AverageRate


AverageRate

Antenatal SteroidsRead MoreSee Quarterly Results


100% 98% 100% 98%


Jul - Sep 2015

33

100%

97%

Oct - Dec 2015

33

100%

98%

Jan - Mar 2016

33

100%

98%

Apr - Jun 2016

33

100%

98%


EmergencyDepartmentRead More


2 2


Rate

Nationwide Average




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

406 minutes400 eligible

Patients

202 309 233 298


Jul - Sep 2015

400

454

302

Oct - Dec 2015

400

411

301

Jan - Mar 2016

400

386

323

Apr - Jun 2016

400

384

309



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

246 minutes400 eligible

Patients

52 122 61 111


Weighted Median Minutes

Nationwide Weighted Median Minutes



Jul - Sep 2015

400

214

116

Oct - Dec 2015

400

269

118

Jan - Mar 2016

400

261

132

Apr - Jun 2016

400

236

123


ImmunizationRead More


2 2




AverageRate


AverageRate

Influenza ImmunizationRead MoreSee Quarterly Results


100% 94% 99% 96%


Weighted Median Minutes

Nationwide Weighted Median Minutes



Jul - Sep 2015

____1

____1

____1

Oct - Dec 2015

503

97%

93%

Jan - Mar 2016

503

100%

95%

Apr - Jun 2016

____1

____1

____1


Rate

Nationwide Average


Documents

Quality Report - Americaneagle.compr-pdf-1vwb01.americaneagle.com/qualitycheck/files/28d...2016/08/17 · Quality Report University of North Carolina Hospitals HCO ID: 6478 101 Manning