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Methodist Hospitals - Northlake Campus
Gary, Indiana 46402-6099
Preventing and Responding to Patient Harm
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Effective Leadership to Prevent Errors |
Hospitals should take meaningful steps to raise awareness about patient safety, hold leadership accountable for reducing unsafe practices, provide resources to implement a patient safety program, and develop systems and structures to support action to improve patient safety. |
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Staff Work Together to Prevent Errors |
Hospitals should assess their culture of safety and hold leadership accountable for implementing policies, procedures, and staff education to improve the culture of safety. |
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Support for Nursing Workforce |
Hospitals should assess their nursing staff levels and core competencies, included nurses in leadership, and develop and implement plans to address any areas of improvement. |
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Handwashing |
Hospitals should regularly monitor hand hygiene practices for everyone interacting with patients, and give feedback to ensure compliance. Hospitals should foster a culture of good hand hygiene, offer training and education, and provide equipment, such as paper towels, soap dispensers, and hand sanitizer. |
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Appropriate Use of Antibiotics |
Hospitals should have a program to combat antibiotic over-prescribing that includes all seven (7) core elements developed by the Centers for Disease Control and Prevention (CDC). |
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Responding to Never Events |
Hospitals should have a never events policy that includes all nine (9) actions that should occur following a “never event,” which includes apologizing to the patient and not charging for costs associated with the never event. |
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Medication Safety
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Safe Medication Administration |
Hospitals should have nurses and other clinicians use BCMA in all medical/surgical units, intensive care units, and labor and delivery units to scan the patient and medication prior to administration at least 95% of the time. The BCMA system includes decision support to prevent errors and the hospital has processes to prevent workarounds. |
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Safe Medication Ordering |
Hospitals should enter at least 85% of inpatient medication orders through the CPOE system. |
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Medication Reconciliation |
Hospitals should use a nationally endorsed protocol to track how well they are collecting and maintaining inpatient medication lists. |
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Medication Documentation for Elective Outpatient Procedure Patients |
Hospitals should document 90% or more of home medications, visit medications, and allergies/adverse reaction(s) in the patients’ clinical record. |
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Healthcare Associated Infections
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Infection in the Blood |
Hospitals should have fewer than expected central-line associated blood stream infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
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This hospital was asked to report its infection data directly to The Leapfrog Group and chose not to. However, some information about this hospital’s infection record may be available through the Centers for Medicare and Medicaid Services. |
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Infection in the Urinary Tract |
Hospitals should have fewer than expected catheter-associated urinary tract infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
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C. difficile Infection |
Hospitals should have fewer than expected colon infections from C. diff bacteria. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
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This hospital was asked to report its infection data directly to The Leapfrog Group and chose not to. However, some information about this hospital’s infection record may be available through the Centers for Medicare and Medicaid Services. |
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MRSA Infection |
Hospitals should have fewer than expected antibiotic resistant bacterial infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
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This hospital was asked to report its infection data directly to The Leapfrog Group and chose not to. However, some information about this hospital’s infection record may be available through the Centers for Medicare and Medicaid Services. |
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Surgical Site Infection After Colon Surgery |
Hospitals should have fewer than expected surgical site infections after major colon surgery. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
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This hospital was asked to report its infection data directly to The Leapfrog Group and chose not to. However, some information about this hospital’s infection record may be available through the Centers for Medicare and Medicaid Services. |
Maternity Care
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Cesarean Sections |
This is defined as first-time mothers giving birth to a single baby, at full-term, in the head-down position deliver their babies through a C-section. Hospitals should have a rate of C-sections of 23.9% or less. |
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Early Elective Deliveries |
This is defined as mothers being scheduled for cesarean sections or medication inductions prior to 39 weeks gestation without a medical reason. Hospitals should have a rate of early elective deliveries of 5% or less. |
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Episiotomies |
This is defined as mothers having an incision made in the perineum (the birth canal) during childbirth. Hospitals should have a rate of episiotomies of 5% or less. |
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Maternity Care Processes |
Hospitals should screen at least 90% of babies for jaundice and at least 90% of women undergoing a cesarean section receive treatment to prevent blood clots. |
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High-Risk Deliveries |
Hospitals should deliver at least 50 very-low birth weight babies per year and ensure that at least 90% of mothers receive antenatal steroids prior to delivery OR the hospital must maintain a lower-than-average morbidity/mortality rate for very-low birth weight babies and ensure that at least 90% of mothers receive antenatal steroids prior to delivery. |
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Pediatric Care
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Experience of Children and Their Parents |
Hospitals should perform better than most hospitals in five (5) areas:
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Radiation Dose for Abdomen/Pelvis Scans |
Hospitals should use a CT radiation dose for routine CT scans of the abdomen and pelvis that falls within national benchmarks. |
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Radiation Dose for Head Scans |
Hospitals should have an average radiation dose for routine CT scans of the head that falls within national benchmarks. |
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Critical Care
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Specially Trained Doctors Care for Critical Care Patients |
Hospitals should have intensivists present on-site at least eight hours a day, seven days per week or has intensivists present via 24/7 telemedicine with some on-site intensivist presence. When not in the ICU, the intensivist immediately responds to calls and has another physician or trained clinician who can immediately reach the patient. |
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Complex Adult Surgery
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Carotid Artery Surgery |
Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 10 procedures annually. |
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Mitral Valve Repair and Replacement |
Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. |
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Open Aortic Procedures |
Hospitals should perform at least 10 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. |
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Bariatric Surgery for Weight Loss |
Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. |
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Esophageal Resection for Cancer |
Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. |
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Lung Resection for Cancer |
Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 15 procedures annually. |
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Pancreatic Resection for Cancer |
The hospital performs at least 20 procedures annually, and as part of their process for privileging surgeons, ensures that each surgeon performs at least 10 procedures annually. |
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Rectal Cancer Surgery |
Hospitals should perform at least 16 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 6 procedures annually. |
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Care for Elective Outpatient Surgery Patients
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Elective Outpatient Surgery Recovery Staffing - Adult |
Hospitals should ensure that a specially certified clinician and at least one physician or nurse anesthetist are present and immediately available while an adult patient is present until discharge. |
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Elective Outpatient Surgery Recovery Staffing - Pediatric |
Hospitals should ensure that a specially certified clinician and at least one physician or nurse anesthetist are present and immediately available while a pediatric patient is present until discharge. |
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Safe Surgery Checklist - Elective Outpatient Surgery |
Hospitals should go through all the elements of a complete safe surgery checklist on all patients every time a procedure is performed. |
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Experience of Patients Undergoing Elective Outpatient Surgery |
Hospitals should perform better than most on four (4) areas including: (a) rating facilities and staff (b) communication about the procedure, (c) patients’ overall rating of the facility, and (d) patients willingness to recommend the facility. |
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Methodist Hospitals - Northlake Campus
600 Grant Street
Gary, Indiana 46402-6099
Methodist Hospitals - Northlake Campus has DECLINED TO RESPOND