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Miami Valley Hospital
Dayton, Ohio 45409-2793
Preventing and Responding to Patient Harm
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| 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. |
 CONSIDERABLE ACHIEVEMENT |
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This hospital scored 101.54 out of 120.00 possible points. |
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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. |
 SOME ACHIEVEMENT |
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This hospital scored 60.00 out of 120.00 possible points. |
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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. |
 ACHIEVED THE STANDARD |
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This hospital scored 100.00 out of 100.00 possible points. |
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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. |
 NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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). |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
Medication Safety
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| Safe Medication Ordering |
Hospitals should enter at least 85% of inpatient medication orders through the CPOE system. |
ACHIEVED THE STANDARD |
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This Hospital's Percentage of Inpatient Medication Orders Entered Electronically: 85% or greater |
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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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
Healthcare Associated Infections
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
Maternity Care
| Measure name | Leapfrog’s Standard | Hospital’s Progress | ||||||
|---|---|---|---|---|---|---|---|---|
| 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. |
SOME ACHIEVEMENT |
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This hospital's rate of Cesarean sections is: 28.4% |
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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. |
ACHIEVED THE STANDARD |
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This hospital's rate of early elective deliveries is: 0.0% |
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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. |
ACHIEVED THE STANDARD |
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This hospital's rate of episiotomies is: 2.6% |
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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. |
ACHIEVED THE STANDARD |
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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. |
CONSIDERABLE ACHIEVEMENT |
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More Information
| Number of Live Births |
The hospital had 3,867 live births (i.e., liveborn infants) at this hospital location for the reporting time period. |
Pediatric Care
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| Experience of Children and Their Parents |
Hospitals should perform better than most hospitals in five (5) areas:
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NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| Radiation Dose for Head Scans |
Hospitals should have an average radiation dose for routine CT scans of the head that falls within national benchmarks. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
Critical Care
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| 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. |
 LIMITED ACHIEVEMENT |
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This hospital achieved the standard using on-site intensivist coverage. |
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Complex Adult Surgery
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
Care for Elective Outpatient Surgery Patients
| Measure name | Leapfrog’s Standard | Hospital’s Progress |
|---|---|---|
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
| 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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
Miami Valley Hospital
1 Wyoming Street
Dayton, Ohio 45409-2793
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