Sharon Regional Medical Center
Sharon, Pennsylvania 16146-3395
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. |
 SOME ACHIEVEMENT |
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This hospital scored 92.31 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. |
 CONSIDERABLE ACHIEVEMENT |
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This hospital scored 100.00 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. |
SOME ACHIEVEMENT |
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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. |
ACHIEVED THE STANDARD |
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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. |
ACHIEVED THE STANDARD |
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| Safe Medication Ordering |
Hospitals should enter at least 85% of inpatient medication orders through the CPOE system. |
CONSIDERABLE ACHIEVEMENT |
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This hospital's percentage of inpatient medication orders entered electronically: 50-74% This hospital's score on the CPOE Evaluation Tool: Full Demonstration of 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. |
CONSIDERABLE ACHIEVEMENT |
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This hospital's rate of unintentional discrepancies per medication is: 0.189 |
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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. |
CONSIDERABLE ACHIEVEMENT |
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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. |
ACHIEVED THE STANDARD |
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This hospital’s standardized infection ratio (SIR) is: 0.000 Note: The standardized infection ratio (SIR) includes some data collected during the COVID-19 pandemic. |
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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: 0.000 Note: The standardized infection ratio (SIR) includes some data collected during the COVID-19 pandemic. |
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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: 0.375 Note: The standardized infection ratio (SIR) includes some data collected during the COVID-19 pandemic. |
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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. |
CONSIDERABLE ACHIEVEMENT |
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This hospital’s standardized infection ratio (SIR) is: 0.556 Note: The standardized infection ratio (SIR) includes some data collected during the COVID-19 pandemic. |
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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 Note: The standardized infection ratio (SIR) includes some data collected during the COVID-19 pandemic. |
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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 23.6% or less. |
SOME ACHIEVEMENT |
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This hospital's rate of Cesarean sections is 27.9% |
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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. |
CONSIDERABLE ACHIEVEMENT |
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This hospital's rate of episiotomies is 9.1% |
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| Screening Newborns for Jaundice Before Discharge |
Hospitals should screen at least 90% of babies for jaundice. |
ACHIEVED THE STANDARD |
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This hospital's rate of screening newborns for jaundice before discharge is 100.0% |
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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. |
ACHIEVED THE STANDARD |
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This hospital's rate of preventing blood clots in women undergoing cesarean section 98.9% |
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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. |
DOES NOT APPLY |
More Information
| Number of Live Births |
The hospital had 319 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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DOES NOT APPLY |
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This hospital does not admit pediatric patients or had too few pediatric admissions to administer the patient experience survey. |
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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. |
ACHIEVED THE STANDARD |
| Radiation Dose for Head Scans |
Hospitals should have an average radiation dose for routine CT scans of the head that falls within national benchmarks. |
CONSIDERABLE ACHIEVEMENT |
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 |
Complex Adult and Pediatric 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. |
CONSIDERABLE ACHIEVEMENT |
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This hospital performed 25 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. 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. |
LIMITED ACHIEVEMENT |
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This hospital performed 3 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. This hospital does not participate in the Society of Thorasic's Surgeons Adult Cardiac Surgery Database. 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 1 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. |
LIMITED ACHIEVEMENT |
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This hospital performed 48 bariatric surgeries for weight loss compared to Leapfrog’s standard of 50 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 bariatric surgeries for weight loss. Additionally, this hospital does not have protocols in place to ensure that bariatric surgery for weight loss is only performed on patients that meet defined criteria. |
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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. |
DOES NOT APPLY |
| 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. |
DOES NOT APPLY |
| 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. |
DOES NOT APPLY |
| 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. |
DOES NOT APPLY |
| 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. |
CONSIDERABLE ACHIEVEMENT |
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This hospital performed 137 total hip replacement surgeries compared to Leapfrog’s standard of 50 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 25 procedures annually for total hip replacement surgeries. Additionally, this hospital does not have protocols in place to ensure that total hip replacement surgery is only performed on patients that meet defined criteria. |
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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. |
CONSIDERABLE ACHIEVEMENT |
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This hospital performed 202 total knee replacement surgeries compared to Leapfrog’s standard of 50 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 25 procedures annually for total knee replacement surgeries. Additionally, this hospital does not have protocols in place to ensure that total knee replacement surgery is only performed on patients that meet defined criteria. |
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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. |
DOES NOT APPLY |
Elective Outpatient Surgery - Adult
Dermatology (Skin)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Complex Skin Repairs | 26 |
Gastroenterology (Stomach and Digestive)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Upper GI Endoscopies | 1,068 | |
| Other Upper GI Procedures | 79 | |
| Small Intestine and Stomal Endoscopies | 3 | |
| Lower GI Endoscopies | 1,379 |
General Surgery
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Cholecystectomies and Common Duct Explorations | 171 | |
| Hemorrhoid Procedures | 17 | |
| Inguinal and Femoral Hernia Repairs | 121 | |
| Laparoscopies | 6 | |
| Lumpectomies and Quadrantectomies of Breast | 27 | |
| Mastectomies | 8 | |
| Other Hernia Repairs | 72 |
Neurosurgery
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Spinal Fusion Procedures | 2 |
Obstetrics and Gynecology
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Cervix Procedures | 14 | |
| Hysteroscopies | 155 | |
| Uterus and Adnexa Laparoscopies | 57 |
Ophthalmology (Eyes)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Anterior Segment Eye Procedures | 278 | |
| Posterior Segment Eye Procedures | 1 | |
| Other Eye Procedures | 18 |
Orthopedic (Bones and Joints)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Finger, Hand, Wrist, Forearm, and Elbow Procedures | 462 | |
| General Orthopedic Procedures | 56 | |
| Hip Procedures | 7 | |
| Knee Procedures | 232 | |
| Shoulder Procedures | 284 | |
| Spine Procedures | 0 | |
| Toe, Foot, Ankle, and Leg Procedures | 81 |
Otolaryngology (Ear, Nose, Mouth, and Throat)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Ear Procedures | 10 | |
| Mouth Procedures | 1 | |
| Nasal and Sinus Procedures | 46 |
Plastic and Reconstructive Surgery
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Breast Repairs or Reconstructions | 0 | |
| Skin Grafts and Repairs | 57 |
Urology (Urinary Tract, Male Reproductive)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Circumcisions | 2 | |
| Cystourethroscopies | 148 | |
| Male Genital Procedures | 7 | |
| Urethra Procedures | 26 | |
| Vaginal Repair Procedures | 8 |
Elective Outpatient Surgery - Pediatric
Gastroenterology (Stomach and Digestive)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Lower GI Endoscopies | 1 | |
| Other Upper GI Procedures | 0 | |
| Small Intestine and Stomal Endoscopies | 0 | |
| Upper GI Endoscopies | 0 |
Ophthalmology (Eyes)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Anterior Segment Eye Procedures | 0 | |
| Other Eye Procedures | 2 |
Orthopedic (Bones and Joints)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Finger, Hand, Wrist, Forearm, and Elbow Procedures | 34 | |
| General Orthopedic Procedures | 5 | |
| Hip Procedures | 0 | |
| Knee Procedures | 16 | |
| Shoulder Procedures | 15 | |
| Spine Procedures | 0 | |
| Toe, Foot, Ankle, and Leg Procedures | 5 |
Otolaryngology (Ear, Nose, Mouth, and Throat)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Ear Procedures | 20 | |
| Mouth Procedures | 0 | |
| Nasal and Sinus Procedures | 4 | |
| Pharynx, Adenoid, and Tonsil Procedures | 4 |
Urology (Urinary Tract, Male Reproductive)
| Procedure | Number of Procedures Performed Annually | |
|---|---|---|
| Cystourethroscopies | 1 | |
| Male Genital Procedures | 0 | |
| Urethra Procedures | 0 | |
| Vaginal Repair Procedures | 0 |
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. |
ACHIEVED THE STANDARD |
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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. |
ACHIEVED THE STANDARD |
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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. |
CONSIDERABLE ACHIEVEMENT |
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| Experience of Patients Undergoing Elective Outpatient Surgery |
Hospitals should perform better than most on four (4) areas including: (a) facilities and staff (b) communication about the procedure, (c) patients’ overall rating of the facility, and (d) patients willingness to recommend the facility. |
LIMITED ACHIEVEMENT |
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Performance on the following four domains of the Outpatient and Ambulatory Surgery (OAS) CAHPS Survey make up a hospital’s score on Leapfrog’s “Experience of Patients Undergoing Elective Outpatient Surgery” measure. “Top Box Score” represents the percentage of respondents who gave the most favorable response.
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More Information
| Patient Consent for Elective Outpatient Surgery |
The hospital provides written surgical consent forms the day of their procedure. |
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| Patient Consent to Anesthesia for Elective Outpatient Surgery |
The hospital provides written anesthesia consent forms the day of their procedure. |
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| Patient Selection |
The hospital does not have a screening protocol to determine whether a patient’s procedure can safely be performed on an outpatient basis, and the protocol includes the following components:
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Sharon Regional Medical Center
740 East State Street
Sharon, Pennsylvania 16146-3395
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