Regional West Medical Center
Scottsbluff, Nebraska 69361-4695
Patient Rights and Ethics
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Billing Ethics |
Hospitals should provide patients with complete billing information and access to a representative that can quickly resolve billing issues. In addition, hospitals should not sue patients over late or unpaid bills. |
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Health Care Equity |
Hospitals should examine their own data to identify any differences in processes or outcomes for patients of different races and ethnicities, and patients who speak different languages. Hospitals should also put action plans in place if differences are identified. |
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Informed Consent |
Hospitals should ensure that all patients are fully aware of risks and alternatives prior to procedures. |
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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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Preventing Patient Harm
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Nursing and Bedside Care for Patients |
Hospitals should have nurse staffing plans in place that ensure there are enough nurses of all types (i.e., registered nurses, licensed practical nurses, or unlicensed assistive personnel) to provide direct care to patients in medical, surgical, or med-surg units each day. |
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Nursing Care for Patients |
Hospitals should have nurse staffing plans in place that ensure there are enough registered nurses (RNs) to provide direct care to patients in medical, surgical, or med-surg units each day. |
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Percentage of Nursing Staff who are Registered Nurses (RNs) |
Hospitals should have nurse staffing plans in place that ensure the proportion of nursing hours performed by registered nurses (RNs) is adequate. |
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Percentage of Registered Nurses (RNs) who have a Bachelor’s Degree in Nursing |
Hospitals should have a high proportion of highly trained and skilled registered nurses (RNs) who have an advanced nursing degree. |
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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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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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Medication Safety
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Safe Medication Ordering |
Hospitals should enter at least 85% of inpatient medication orders through the CPOE system, and should fully demonstrate their CPOE system meets the national safety standard for decision support. |
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Medication Reconciliation |
Hospitals should have a rate of unintentional medication discrepancies per medication that is lower than or equal to the 50th percentile (where lower performance is better) nationally. |
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Safe Medication Administration |
Hospitals should have nurses and other clinicians use BCMA in all medical/surgical units, intensive care units, labor and delivery units, pre-operative and post-anesthesia care 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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Medication Documentation for Elective Outpatient Surgery 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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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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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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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. |
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 have 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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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 Pediatric Abdomen/Pelvis Scans |
Hospitals should have an average radiation dose for routine pediatric CT scans of the abdomen and pelvis that falls within national benchmarks. |
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Radiation Dose for Pediatric Head Scans |
Hospitals should have an average radiation dose for routine pediatric CT scans of the head that falls within national benchmarks. |
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Congenital Heart Surgery for Infants (Norwood Procedure) |
Hospitals should perform at least 8 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 5 procedures annually. |
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Maternity Care
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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High-Risk Deliveries |
Hospitals should deliver at least 50 very-low birth weight babies per year OR the hospital must maintain a lower-than-average morbidity/mortality rate for very-low birth weight babies. |
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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 who deliver their babies through a C-section. Hospitals should have a rate of C-sections of 23.6% 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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Screening Newborns for Jaundice Before Discharge |
Hospitals should screen at least 90% of babies for jaundice. |
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Preventing Blood Clots in Women Undergoing Cesarean Section |
At least 90% of women undergoing a cesarean section receive treatment to prevent blood clots. |
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Complex Adult Surgery
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Carotid Endarterectomy |
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. In addition, hospitals should participate in a national clinical registry and achieve the same or better outcomes when compared to others who also perform this procedure. |
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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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Total Knee Replacement Surgery |
Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. |
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Total Hip Replacement Surgery |
Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. |
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Safe Surgery Checklist - Complex Surgery |
Hospitals should go through all the elements of a complete safe surgery checklist on all patients every time a surgery is performed. |
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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 is 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 is present and immediately available while 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 regarding the experience of adult patients: (a) 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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Unplanned Hospital Visits after Colonoscopy |
Unplanned hospital visits can occur when patients experience complications after a colonoscopy procedure. Facilities should have a rate of unplanned hospital visits that is lower than most hospitals and surgery centers. |
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Regional West Medical Center
4021 Avenue B
Scottsbluff, Nebraska 69361-4695
Regional West Medical Center has DECLINED TO RESPOND