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Longview Regional Medical Center
Longview, Texas 75605-5191
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. |
 ACHIEVED THE STANDARD |
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This hospital scored 120.00 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. |
ACHIEVED THE STANDARD |
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This hospital scored 120.00 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). |
ACHIEVED THE STANDARD |
| 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. |
 LIMITED ACHIEVEMENT |
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. |
 CONSIDERABLE ACHIEVEMENT |
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| 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. |
LIMITED ACHIEVEMENT |
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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. |
NOT AVAILABLE Due to the COVID-19 pandemic, data for this measure is not available |
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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. |
LIMITED ACHIEVEMENT |
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This hospital’s standardized infection ratio (SIR) is: 2.096 |
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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. |
ACHIEVED THE STANDARD |
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This hospital’s standardized infection ratio (SIR) is: 0.312 |
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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. |
ACHIEVED THE STANDARD |
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This hospital’s standardized infection ratio (SIR) is: 0.335 |
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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. |
LIMITED ACHIEVEMENT |
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This hospital’s standardized infection ratio (SIR) is: 1.780 |
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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. |
ACHIEVED THE STANDARD |
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This hospital’s standardized infection ratio (SIR) is: 0.000 |
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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: 27.2% |
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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. |
CONSIDERABLE ACHIEVEMENT |
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This hospital's rate of early elective deliveries is: 10.0% |
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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. |
SOME ACHIEVEMENT |
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This hospital's rate of episiotomies is: 14.3% |
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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. |
SOME ACHIEVEMENT |
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More Information
| Number of Live Births |
The hospital had 2,347 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. |
ACHIEVED THE STANDARD |
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This hospital achieved the standard using telemedicine and 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. |
SOME ACHIEVEMENT |
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This hospital performed 58 carotid artery surgeries compared to Leapfrog’s standard of 20 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 10 procedures annually for carotid artery surgery. Additionally, this hospital does not have protocols in place to ensure that carotid artery surgeries are only performed on patients that meet defined criteria. |
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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. |
LIMITED ACHIEVEMENT |
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This hospital performed 22 mitral valve repairs and replacements compared to Leapfrog’s standard of 40 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 20 procedures annually for mitral valve repair and replacement. Additionally, this hospital does not have protocols in place to ensure that mitral valve repairs and replacements are only performed on patients that meet defined criteria. |
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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. |
LIMITED ACHIEVEMENT |
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This hospital performed 6 open aortic procedures compared to Leapfrog’s standard of 10 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 7 procedures annually for open aortic procedures. Additionally, this hospital does not have protocols in place to ensure that open aortic procedures are only performed on patients that meet defined criteria. |
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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. |
DOES NOT APPLY |
| 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. |
LIMITED ACHIEVEMENT |
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This hospital performed 3 esophageal resections for cancer compared to Leapfrog’s standard of 20 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 7 procedures annually for esophageal resection for cancer. Additionally, this hospital does not indicate having a multidisciplinary tumor board that prospectively reviews cancer cases to ensure that esophageal resections for cancer are only performed on patients that meet defined criteria. |
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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. |
LIMITED ACHIEVEMENT |
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This hospital performed 24 lung resections for cancer compared to Leapfrog’s standard of 40 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 15 procedures annually for lung resection for cancer. Additionally, this hospital does not indicate having a multidisciplinary tumor board that prospectively reviews cancer cases to ensure that lung resections for cancer are only performed on patients that meet defined criteria. |
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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. |
LIMITED ACHIEVEMENT |
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This hospital performed 1 pancreatic resections for cancer compared to Leapfrog’s standard of 20 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 10 procedures annually for pancreatic resection for cancer. Additionally, this hospital does not indicate having a multidisciplinary tumor board that prospectively reviews cancer cases to ensure that pancreatic resections for cancer are only performed on patients that meet defined criteria. |
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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. |
LIMITED ACHIEVEMENT |
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This hospital performed 6 rectal cancer surgeries compared to Leapfrog’s standard of 16 procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog’s minimum surgeon volume standard of at least 6 procedures annually for rectal cancer surgery. Additionally, this hospital does not indicate having national accreditation from the American College of Surgeons or a multidisciplinary tumor board that prospectively reviews cancer cases to ensure that rectal cancer surgery is only performed on patients that meet defined criteria. |
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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 |
Longview Regional Medical Center
2901 North Fourth Street
Longview, Texas 75605-5191
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